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Mental Illness and Substance Abuse

The dual diagnosis of mental illness and substance abuse refers to the presence of a severe psychiatric disorder and abuse of or dependence on alcohol or drugs. This dual diagnosis is referred to in a number of ways, for example, dually diagnosed, dually disordered, MICA (mentally ill chemical abuser), MISA (mentally ill substance abuser), or CAMI (chemical abuse and mental illness) (U.S. Department of Health and Human Services, 1995). Incidence of Mental Illness and Substance Abuse For many people with this dual diagnosis, the substance abuse predates the onset of mental illness and the reasons for using seem to be the same reasons given by people without disabilities who abuse substances. Some researchers hypothesize that the drug use precipitates or induces the mental illness. For other individuals the reasons for using drugs and alcohol may include self-medication to alleviate psychiatric symptoms, to medicate side effects, to be liked by their peers without disabilities, or to...

Dual Diagnosis Substance Abuse and Mental Illness

This chapter deals with the treatment and rehabilitation of persons who have a severe and persistent mental illness and a substance abuse disorder. The person with a severe mental illness has a much greater risk of developing a substance abuse disorder than someone without a mental illness. The difficulties inherent in having two potentially disabling conditions (which we refer to as having a dual diagnosis) are confounded by the fact that the mental illness and substance abuse disorder may interact, each exacerbating or aggravating the other. In addition, coming from different philosophical and educational backgrounds, the service providers for these different conditions often have conflicting and sometimes contradictory approaches. Services have been developed to address these problems and other issues involved in helping this dually diagnosed population. 1. What unique problems are faced when providing services to someone dually diagnosed with a mental illness and a substance abuse...

Substance Abuse and Mental Health Statistics

It is difficult to assess the prevalence of mental illness and substance abuse in many correctional systems with any certainty since in many women's prisons there is inadequate screening when inmates arrive making it impossible to determine the severity of some of these problems. A 2001 survey of services found only 72 of jails for women screen for substance abuse, only 70 screen for mental health problems, 60 screen for physical problems, and fewer than 30 screen for math and reading ability, childhood abuse, spousal abuse, or parenting needs. Worse still, only 10 of women prisoners who are drug abusers are offered treatment (BJS, 2000 Richie et al., 2001). One study of female prisoners in Kentucky found that 90 of inmates had a history of substance abuse problems, 62 reported symptoms of depression, 53 reported anxiety disorders, and 43 reported difficulty in concentration. Women's drug use differs from that of men in many ways. There are gender differences in the etiology of...

Substance Abuse and Dependence

Researchers using something called an odds ratio, which measures the odds of having one disorder if an individual has the other disorder, have measured the rates of comorbid Substance Abuse and PTSD. Studies have revealed the range of odd ratios for comorbid Alcohol Dependence or Abuse is 2.06 to 4.25. This means that if someone has PTSD, his or her odds of having an Alcohol Abuse or Dependence Disorder is anywhere from two to four times higher than if they did not have PTSD. Regarding Substance Abuse or Dependence, the range of odds ratios from various studies is 2.48 to 8.68. Again, this means that the odds of someone with PTSD also having a comorbid Substance Abuse or Dependence Disorder is anywhere from 2.5 times to 8.5 times higher than if he or she did not have PTSD. Posttraumatic Stress Disorder patients with comorbid Substance Abuse or Dependence Disorders have been found to have higher levels of pathology in both disorders, more stressors, higher rates of health care...

Mental Health and Substance Abuse

A range of mental health and substance abuse treatment services are needed in criminal justice settings, as the problem of substance use is more pronounced within the detained population. Survey results among juvenile arrestees provide evidence of illegal drug use with more than half of the males testing positive for at least one drug marijuana was the most frequently detected drug (National Institute of Justice, 1999). Another study concluded that 60 to 87 of female offenders need substance abuse treatment (Prescott, 1998). Substance abuse treatment services are often among the first to be cut during budget reductions. Security and supervision measures are seen as more important obligations than treatment plans when it comes to allocating funds. Substance abuse treatment is not legally mandated in most correctional settings although it has been proven to have a tremendous effect on reducing the rate of recidivism among inmates. Treatment partnerships within the criminal justice...

Prevention of Viral Hepatitis

Primary prevention of infection with HAV and HBV can be achieved through immunization. For HCV, primary prevention of infection activities includes screening and testing of blood donors, virus inactivation of plasma-derived products, risk reduction counseling and services (e.g., substance abuse treatment) for injection-drug users, and implementation and maintenance of infection control practices to prevent exposure to blood. Identification of persons with chronic HBV and HCV infection provides an opportunity to initiate primary prevention activities including vaccination of household, sex, and needle-sharing contacts of persons with chronic HBV infection and counseling to reduce risks for transmitting HBV and HCV to others. In addition, persons with chronic HBV and HCV infection can be provided medical management that can reduce the progression of chronic liver disease. This section summarizes current information, practices, and recommendations to prevent infection with hepatitis...

Other Important Opportunities for HIV Prevention

Through the documentation of the strong relationship between substance use and sexual risk behavior, and the high percentage of substance use of those in the criminal justice system (Bureau of Justice Statistics, 1997), substance abuse treatment is HIV prevention (and very few correctional systems provide substance abuse treatment) (Rich et al., 2001 Fiscella et al., 2004 World Health Organization, 2005 Okie, 2007). voluntarily sign up. There are more substance abusers in our prisons and jails than in alcohol drug treatment programs in the community. An estimated 42 of state prisoners have the comorbidity of substance dependence and mental health problem (Human Rights Watch, 2006). A 2006 Bureau of Justice Statistics report documented the quadrupling of the number of mentally ill prisoners in the past 6 years. Rates of mental health disorders among state prisoners are five times higher than the community rates (Bureau of Justice Statistics, 2006) rates among female prisoners were even...

An Alternative Paradigm for Correctional Health Services

In this view, correctional health services (CHS) seek to improve population health both by treating the conditions that inmates present to facility providers and by offering the knowledge, skills, and referrals that incarcerated people need to protect their health inside the prison or jail and after release. CHS can also serve as referral sites for both facility-based (during incarceration) and community-based (after release) health education, health care, mental health and social services, and also as resource on health for inmates' partners and children in the free world. In this model, the outcome of incarceration is assessed in part on the extent to which the facility has prepared those in its custody for healthier living after release. Finally, from a criminal justice perspective, health problems such as substance abuse, perpetration of or victimization by violence, mental illness, or chronic or infectious diseases can increase recidivism, encourage dependency, or endanger the...

Develop Personal Skills

Build healthy Advocate policies that provide public policy substance abuse, mental health, and other services during incarceration and after release reduce stigma against people returning provide job training and education inside and after release Increased access to and use of substance abuse treatment services, mental health services increased ability to find employment and reduce dependency after release Greater infrastructure for substance abuse and mental health treatment and promotion

Build Healthy Public Policy

In recent years, public health researchers have called attention to the importance to population health of public policies in a variety of sectors, including housing, education, the environment, work, taxation, and criminal justice (Lurie, 2002 McGinnis, Williams-Russo, & Knickman, 2002 Milio, 1998). Recent research on the health of incarcerated populations demonstrates that policies on substance abuse, crime, housing, employment, health care, and other issues can adversely affect their well-being (Blankenship, Smoyer, Bray, & Mattocks, 2005 Freudenberg, Daniels, Crum, & Perkins, 2005 Golembeski & Fullilove, 2005 Holzer, Raphael, & Stoll, 2003 Iguchi et al., 2002 O'Leary & Martins, 2000 Richie et al., 2001). Often these policies impose disproportionate burdens on vulnerable and disenfranchised groups people of color, women, and drug users, and may thus contribute to growing disparities in health (Freudenberg, 2002 Gaiter, Potter, & O'Leary, 2006 Iguchi, Bell, Ramchand, & Fain, 2005)....

Knowledge Psychiatric Diagnostic Comorbidity and Modern Neuropsychiatry

Mental disorders that occur in the presence of substance abuse and dependence that are also DSM-IV-TR defined mental disorders (American Psychiatric Association & Task Force on DSM-IV, 2000), and Does a person with a substance abuse history have other underlying mental disorders While not every case needs all of this information, complex cases with hints of or flagrant presentations of not one but two or more coexisting psychiatric disorders need extensive data collection and high-level clinical judgment. My personal clinical observations in the last two decades suggest that a presentation of substance abuse dependence or ADHD in adults carries a high comorbidity for anxiety spectrum disorders (such as generalized anxiety, obsessive compulsive disorder, panic disorder, and or posttraumatic stress disorder), bipolar disorder, major depression, and a history of traumatic brain injury (TBI). Conversely, a history of TBI means one must rule out any and all of these Axis I disorders. These...

Conceptual Challenges to Creating Effective Treatment and Reentry Programs for Women

Enough to provide employment and education programs and substance abuse treatment, important as those needs are, without also considering these women in their social context, as part of communities and families, and as mothers. Many female prisoners strongly identify with their role as parents. They are motivated to succeed in treatment programs in order to regain or keep custody of their children (Mullings et al., 2003 Surratt, 2003). Not surprisingly, outcome predictors for reentry programs seem to be different for men and for women. Inmates treated in residential treatment followed by outpatient treatment in the community have lower rates of drug relapse and rearrest. But in the case of women, more than with men, there was a distinct correlation with the length of the program. In the case of female inmates the length of time they spent in aftercare was a useful predictor of success. The outcome for women in extended treatment programs was better than the outcome for men (Hall,...

Most Inmates Dont Receive Discharge Planning

The fact that so many released prisoners receive no prerelease preparation further supports the creation of written discharge materials, because a pamphlet or a comprehensive resource guide may be the only information on which they can rely. The parallels to the medical field are surprisingly similar. Makaryus and Friedman (2005) note that after being carefully supervised in the hospital, patients at discharge assume the former responsibilities of the health care team for their own health care (p. 991). The same can be said for the majority of inmates. However, unlike most patients, inmates must also start from the beginning in finding employment, housing, food, clothing and the development of strong social networks to increase their chance of succeeding in the community. Many times the inmate's family is not there to support him, having given up on the inmate for his past transgressions. The inmate is in a situation where with limited help he has to locate and obtain identification,...

HIV and Viral Hepatitis in Corrections A Public Health Opportunity

Further complicating the appropriate management of contagious illnesses among the incarcerated is the high prevalence of comorbidities such as mental illness and substance abuse. Many inmates are distrustful of authority and reluctant to cooperate with health care providers. Fearful of adverse publicity, some jails and prisons have been slow to ask for assistance from outside agencies when faced with infectious disease outbreaks. Furthermore, published guidelines for diagnosis and treatment of communicable diseases are not always readily applicable to the correctional setting. All of these factors contribute to lost opportunities for diagnosis, treatment, prevention, immunization, and harm reduction education. Consequences include the development of preventable complications of untreated illness and missed opportunities for interrupting transmission of infection to the larger community.

Presenting the Evidence

The empirical evidence that exists to date indicates that prisoners deem oral health a priority and that access to oral health services improves the conditions of their mouths. For instance, among prisoners in Maine, smoking and dental health were the most commonly reported health problems after mental health and substance abuse (Maine Civil Liberties Union, 2003). A recent study of continuously incarcerated individuals in the North Carolina prison system found that the prison dental care system was able to markedly improve the oral health of a sample of inmates (Clare, 2002), affirming the idea that dental health improves when access to services is provided. Even still, despite improvement, the remaining dental needs of these felons were deemed to be substantial.

Viral Hepatitis

Immunization of those who are nonimmune, diagnosis and treatment of those who are chronically infected, substance abuse treatment, and harm reduction education in the correctional setting can benefit the free community by decreasing costs associated with chronic viral hepatitis, reducing transmission, and decreasing recidivism (Conklin et al., 1998 Mast et al., 1998 Goldstein et al., 2002). However, significant challenges exist to the implementation of a comprehensive viral hepatitis infection control and prevention program in jail and prison settings. Short stays, transient populations, insufficient interjurisdictional cooperation and communication, inadequate information technology, a shortage of medical expertise, patient distrust, and poor reimbursement all conspire to derail viral hepatitis initiatives in the correctional setting. What follows is a discussion of the burden of viral hepatitis in jails and prisons, and some of the challenges and opportunities that exist for the...

Release Planning

Comprehensive release planning includes transitional housing, continued access to discharge medications and immunizations, and coordination and case-management of long-term specialized care for persons with chronic conditions. Persons diagnosed with chronic HBV infection can benefit from counseling related to preventing transmission to household, sexual, and drug-use contacts. Susceptible contacts of persons diagnosed with chronic HBV infection benefit from hepatitis B vaccination. Persons with chronic hepatitis B or chronic hepatitis C can benefit from (1) counseling regarding ways to reduce further liver damage, (2) referrals to substance abuse treatment and other IDU programs if indicated (http idu substance.htm), and (3) medical referrals to specialists for future treatment.

Discharge Planning

Incarcerated populations have a complexity of discharge planning needs. Following release from correctional facilities, reentrants face urgent housing, employment, financial, and other subsistence needs that often take priority over their healthcare (Hammett et al., 2001). While incarcerated, inmates may lose their employment, housing, eligibility for food stamps, or Medicaid and Social Security benefits. As such, postrelease, reentrants with TB may not have the ability or resources to make or keep follow-up appointments or obtain necessary medications. They may have language, literacy, or cultural barriers, which further complicate their ability to seek care. In addition, reentrants often have mental health or substance use issues that can hinder their ability to access healthcare services. Thus, to be effective, TB discharge planning efforts must be holistic and tailored to the needs of the reentrant. As such, correctional facility discharge planning programs should (1) initiate...

Case Studies

Many jurisdictions have moved to develop new programs and establish parity in terms of services for females. A best-practices study commissioned in 1997 found that while most of the programs they evaluated tried to provide counseling and skills training (though frequently they were underfunded and understaffed), health services were inadequate. There was very little emphasis on providing the young women with information about sexually transmitted diseases, family planning, or parenting skills. Substance abuse treatment was provided at about only half of the programs evaluated, and in many cases this primarily meant referrals to local Twelve Step Programs. Very few of these programs addressed the important issues of victimization and prior abuse, and without that component the needs of these young women would not be met (Bloome et al., 2002). A Michigan program, Project PROVE (Post Release Opportunities for Vocational Education), operates on a different model of empowerment. The...

Active Immunisation

Immunisation against hepatitis B is now recognised as a high priority in preventive medicine in all countries and strategies for immunisation are being revised. Universal vaccination of infants and adolescents is under examination as the strategy to control the transmission of this infection. More than 90 countries now offer hepatitis B vaccine to all children, including the USA, Canada, Italy, France and most western European countries. However, immunisation against hepatitis B is at present recommended in a number of countries with a low prevalence of hepatitis B only to groups that are at an increased risk of acquiring this infection. These groups include individuals requiring repeated transfusions of blood or blood products, prolonged inpatient treatment, patients who require frequent tissue penetration or need repeated circulatory access, patients with natural or acquired immune deficiency and patients with malignant diseases. Viral hepatitis is an occupational hazard among...

Special Treatment Considerations with Dual Diagnoses

Dual diagnosis, the presence of two disorders within one individual, is a common situation. Two of the most prevalent and relevant to severe and persistent mental illness are (1) mental illness and addictive disorders (substance abuse or chemical abuse) and (2) mental illness and developmental disability. Drug abuse is a significant complicating factor, associated with medication noncompli-ance, among other issues. Substance abuse also contributes to relapses, homelessness, medical problems, disruption in employment, and many more problems (Krystal, D'Souza, Madonick, & Petrakis, 1999). The issue of combined mental illness and substance abuse will be dealt with extensively in Chapter 8.

Posttraumatic stress disorder

PTSD secondary to childhood neglect and abuse, especially sexual abuse, is often the underlying psychiatric pathology in dermatological patients who self-induce their lesions. PTSD is often complicated by substance abuse disorders and this often becomes the main focus in treatment. When dissociative symptoms are a prominent feature of the PTSD, the patient may not have recollection of the fact that they self-induced their lesions (Shelley, 1981 Gupta et al., 2000) and may be misdiagnosed as malingerers or attentions seekers and the central role of psychological trauma is often overlooked. PTSD, dissociation and self-injury (Gupta et al., 2000) can be the underlying psychiatric disturbance in some cases of trichotil-lomania and dermatitis artefacta or may complicate the course of other dermato-logical conditions such as acne excoriee or the exacerbation of psoriatic lesions secondary to the Koebner phenomenon.

Clinical Comorbidity Underlined by Overlapping Biological Mechanisms

One emerging theme in the field of substance addiction is the intricate relationship at a molecular level with other mental disorders. Substances of abuse modulate some of the same biochemical pathways and circuits involved in mood and anxiety disorders. It is also increasingly being appreciated that there is a strong interplay with cognitive disorders. Eating disorders can also be viewed from the perspective of a substance abuse disorder, both in aetiology and treatment. Active areas of research include substance abuse propensity and affective disorders, substance abuse as a way of self-treating affective disorders, and substance abuse and cognitive disorders. This ongoing work may have strong practical implications in terms of treatment strategies. Dopaminergic neurotransmission plays a central role in cognition, mood and substance abuse. A study in mice looking at the effects of targeted disruption in mice of dopamine and adenosine 3',5'-monophosphate-regulated phosphoprotein (32...

Day Programming and Evidence Based Practice

When carried out effectively, psychiatric rehabilitation day programs are complex entities providing a host of different services designed to meet the needs of individual consumers. For example, a program might provide its members with (1) case management services for advocacy and supports, (2) skills training, (3) medication evaluation and monitoring, (4) illness management training, (5) family education and support, (6) vocational services, (7) supported education, and (8) integrated services for persons with substance abuse problems. Each of these services, if carried out correctly, is either an evidence-based practice or being tested as a possible evidence-based practice. In fact, the ideal psychiatric rehabilitation day program would consist of a large set of high-fidelity, evidence-based practices that could be offered to consumers on an as-needed or as-requested basis.

Ethical Questions Arising from Managed Care Systems

Current market forces are demanding high-quality health care with improved access and at the lowest possible cost. In addition, there is a new emphasis on accountability both to the payers of insurance and to the public. With regard to the issue of providing quality care at the lowest possible cost, there are considerable pitfalls in the marketplace. The current competitive nature of psychiatric care is driving down the amount of funds that payers are providing for psychiatric and substance abuse treatment. This is especially true in mature managed care markets using capitation as a form of payment. Unfortunately, capitation rates continue to fall while comprehensive psychiatric services are being promised. This leaves many

History of Dual Diagnosis Treatment

People with a psychiatric disorder who abused substances have not always been thought of as having two psychiatric disorders. Psychiatric symptoms were seen as signs of an illness, but substance abuse was often considered bad behavior (Evans & Sullivan, 1990). Many mental health clinicians believed that their clients would cease abusing substances if they received adequate treatment for the psychiatric disorder. Substance abuse counselors often mistook psychiatric symptoms for evidence of substance abuse because abuse of drugs and alcohol may cause symptoms that mimic those of mental illness (Evans & Sullivan, 1990 Miller, 1997). The mental health and substance abuse treatment systems were both unsuccessful in treating individuals with dual disorders. The mental health service provider found that the person with dual disorders was difficult to engage and did not respond to typical mental health treatment. Many in the substance abuse treatment system endorsed abstinence and considered...

Fundamental Treatment Strategies in Providing Integrated Dual Disorders Stages of Treatment

Early efforts at substance abuse treatment for persons with a dual disorder often consisted of demanding abstinence and teaching consumers about the many dangers of drug and alcohol abuse. While some people responded to this approach, for many it was a failure. This service approach was ineffective for those who did not want to stop using substances or lacked the awareness of the consequences of their substance use. Clearly, another approach was needed.

Organization Of Teams For Community Mental Health Care Possible Models

If the move from large mental hospitals to the community is to be accomplished with the conservation of standards of care, most of the functions of the hospitals must be replicated by extramural services 6 . For people with long-standing and severe mental illness, continuity of contact and of care must be managed by teams of clinicians with far less reliance on segregated residence. It will not always be possible to avoid hospital admission, and thus there must be effective links between acute hospital units and the community workers. It is now generally accepted that continuous and effective care is best served by cohesive teams of workers. These community mental health teams probably function better if they involve collaboration between a range of different disciplines, allowing a pooling of skills. What is not clear is whether a generic team of this type can be used to cover all the needs of people with severe mental disorder living in the community. In some places, other teams...

Principles of Treatment for People with Dual Diagnoses

Integrated treatment Mental health and substance abuse services are provided concurrently by the same clinician or clinical team. The clinician(s) is knowledgeable 6. Relapse prevention interventions It is well known that there is an increased danger of substance abuse relapse for people with dual disorders. Some experts assert that relapse is almost inevitable. Services that assist the individual in planning strategies to address relapse are recommended.

Dual Diagnosis Treatment in Groups

Stage-wise treatment groups provide interventions relevant to the different stages of recovery from substance abuse engagement, persuasion, active treatment, and relapse prevention. Typically, clients in the engagement stage do not attend these groups although they may attend the persuasion groups. The persuasion groups use education and motivational interviewing to increase awareness of the consequences of substance use and to examine the discrepancy between behaviors and personal goals. People in the active treatment and relapse prevention stages attend active treatment groups. These groups include mutual support, skill building including social skills, relapse prevention strategies, and encouragement to use community self-help programs (Mueser & Noordsy, 1996).

Integrated Services An Evidence Based Practice

An evidence-based practice (EBP) is a treatment practice that has been shown to have positive consumer outcomes through controlled research studies across a variety of treatment sites. When someone has two simultaneous disorders such as substance abuse and mental illness, the integration of treatments for both disorders has consistently been shown to have better treatment outcomes than traditional treatment. Specifically, this integration refers to the concurrent treatment of both conditions by the same clinicians trained in both disorders. While developed primarily for co-occurring mental illness and substance abuse problems, service integration is generally considered the preferred strategy when faced with other co-occurring disorders (e.g., mental illness and development disability). In general, evidence leans toward the integration of all services regardless of the presence of an additional disorder (e.g., simultaneously providing psychiatric treatment and supported employment).

Outcomes of the Evidence Based Practice

Integrated approaches for co-occurring mental illness and substance abuse problems have been found to be superior to nonintegrated approaches. Studies have demonstrated positive outcomes such as reduced substance abuse, reduction of psychiatric symptoms, increased housing stability, reduced hospitalizations, fewer arrests, improved functional status, and improved quality of life (Drake et al., 2002). While the integrated approach is not a panacea with respect to the conditions it is designed to address, it has been shown to be superior to either the sequential or parallel service models described earlier in this Chapter (Mueser et al., 2003b).

Discussion of Rogers Story

Roger apparently went though much of his adult life with little or no insight into his many problems. Sadly, this is quite common for dually diagnosed persons like Roger. One might effectively argue that in some ways Roger exhibited personal strength, some might still call it ego strength. Not believing he was sick, when the system was going to hospitalize him he left and began a life on the streets. Yet, while he was resourceful enough to survive on the street, that strength relegated him to the life of a reclusive outsider living alone and in poverty. The problems Roger had with his first encounters with the treatment system have been experienced by many people. Initially, a mental health system of credentialed professionals generally funded based on medical diagnoses and an emerging substance abuse system mostly staffed by ex-alcoholics and addicts and funded by grants and private donations represented two very different worlds. Recognition of the increasing number of dually...

Clinical Features of Delirium

Failure to report use of medications or substance abuse is a common cause of withdrawal delirium in hospitalized patients. Infection and medication interaction or toxicity is a common cause of delirium in the elderly. F. The incidence of delirium in hospitalized patients is 10-15 , with higher rates in the elderly. Other patients at risk include those with known CNS disorders, substance abusers, and HIV-positive patients.

Supported Education An Emerging Evidence Based Practice

The number of research studies examining the outcomes of specific supported education models is relatively limited. Nevertheless, the Center for Mental Health Services at the U.S. Substance Abuse and Mental Health Administration (CMHS SAMSHA) has already endorsed supported education as an exemplary service (Mowbray, Bellamy, Megivern, & Szilvagyi, 2001 Mowbray & Collins, 2002). Moving a service approach from an exemplary or promising practice to one that meets the criteria for being evidence based can be a long journey. Carol Mowbray, who was a researcher at the University of Michigan School of Social Work and who is profiled in this chapter (see Box 10.1), undertook a first step in this process.

Treatment of Comorbid Disorders and Associated Symptoms

More often than not, PTSD sufferers are plagued by comorbid or other association symptoms and conditions. Matthew Friedman states, people with PTSD exhibit abnormalities in almost every psychobiological system (p. 95). Kessler et al. (1995) estimate that more than 80 percent of individuals with PTSD have a comorbid psychiatric condition. Such disorders and related conditions as depression, Generalized Anxiety Disorder, Panic Disorder, psychosis, substance abuse, and irritability and anger should be addressed with their respective and indicated medications, with proper attention paid to interaction effects and how the treatment of these issues ties into the overall clinical picture. Selective serotonin reuptake inhibitors are implicated for treatment of depression and Anxiety Disorders as well. Effective medications for psychotic symptoms include Zyprexa and Seroquel. Methadone has been effectively used in the treatment of Opioid Dependence. Fluoxetine has been used successfully in the...

Sources for Further Study

Behavior and Medicine. 3d ed. Seattle Hogrefe & Huber, 2001. This large volume covers an extensive area of behavior and medicine, which include stress and various behaviors which may affect physiological health. The articles cover such behavioral issues as substance abuse, stress management, pain, placebos, AIDS, cardiovascular risk, and adherence to medical regimens. Other behavioral issues are covered which relate to love and work, as well as developmental issues from infancy to death, dying and grief. The book is readable and includes illustrations, bibliographies, summaries, and study questions at the end of each article.

Long Term Management Phase

In the consolidation stage, the focus should be on community-based approaches, and existing staff should be properly mobilized and trained, starting from local level to the national level. Ongoing training and supervision of the staff should be carried out. It is important to coordinate and supervise these activities, with one department of the local government or an international agency taking the lead. All the key governmental and nongovernmental organizations should be involved and proper directions given according to the needs, keeping in mind the socio-cultural political viewpoint. Family counselling community dramas to relive previous traumatic experience and to discuss means of coping cultural activities sports discussions on stigma, the problems of women and children, and human rights and coping strategies are some of the activities that should be considered at this stage. Since the eventual aim is to build up the morale of the people and help them to rebuild their lives, all...

Self Help for Persons with Dual Diagnoses

Participating in self-help groups may be even more important for people dealing with the dual diagnoses of both a mental illness and a substance abuse disorder. Historically, individuals with dual disorders were the first to be referred to self-help groups focused on recovery from substance abuse. Sadly, these referrals were more often caused by an inability or unwillingness of mental health professionals to deal with the substance abuse problem than an appreciation of the benefits of self-help. Still, professionals were aware that attendance at these substance abuse-related self-help groups was often helpful in the recovery process. For many professionals this knowledge led to an appreciation of the contributions self-help could make for persons with psychiatric disabilities. Individuals who have both a mental illness and a substance abuse disorder are still the consumers most likely to be referred to self-help groups. As discussed in Chapter 8, people with a dual diagnosis require...

The Use Of Health Care Services By The Homeless Mentally

Suicide attempts were an important factor in being in contact with the system for people with schizophrenia, it multiplied the number of contacts by 20 for people with alcohol problems, by 5 and for drug addicts, by 6.6. The presence of a concomitant physical disease increased contacts for psychiatric symptoms it multiplied the number of contacts by 4 in the case of alcohol-related disorders, and hospitalization was multiplied by 3.7 for homeless people with schizophrenia. with health care than the remainder. Among those suffering from schizophrenia, 9.6 were receiving care in free public clinics (run by the public sector system) and 16.8 in outpatient clinics, more than all other groups. By contrast, those suffering from depressive disorders and alcohol- or drug-related disorders were more frequently cared for at hospital casualty departments and hospitalised. They also had the least frequent contact with general practitioners. When asked about contact in the two preceding weeks,...

Risk Factors For Homelessness In The Mentally

A substantial number of homeless people, as opposed to only a few controls, had behavioural problems in childhood. The authors stated that, although a complex relationship between childhood behaviour and a predisposition to homeless is conceivable (for example, through compromising childhood placements and subsequent support), there may also be a direct link, with antisocial behaviour persisting into adulthood 38 . Since many subjects reported extensive criminal records as well as experiences of both alcohol- and drug-related problems, it was only the latter that persisted in their multivariate model. Substance abuse acts in a variety of ways to increase the risk of becoming homeless, diverting money from housing and other daily living expenses, as well as leading to a loss of social support and contributing to criminal behaviour 39 . The latter in turn may jeopardize housing by causing conflict with family and landlords, or by leading to imprisonment. The authors add that coexistence...

Pathways To Homelessness For The Mentally

Like the non-mentally-ill homeless, the mentally ill homeless are at very high risk of substance abuse. Homeless subjects have almost twice the prevalence of alcohol dependence and six times the prevalence of drug abuse of housed subjects. These comparisons show that homeless persons, whether or not they are mentally ill, are more likely to be socially disadvantaged (less educated, ethnic minorities) and to have a high likelihood to be currently dependent on alcohol or drugs. Sullivan et al.'s analyses 14 do not support the notion that mental illness represents a distinctive pathway to homelessness, but rather that the relationship between mental illness and homelessness is both complex and dynamic. While programmes that attempt to improve the symptoms and functioning of homeless adults and to alleviate the chronic stresses of homelessness certainly help some individuals, they fail to address the deeper origins of homelessness, arising from both the structural and...

Dual Diagnosis and the Family

The impact on the family unit of a member with a dual diagnosis of psychiatric disability and either a substance abuse disorder or a developmental disability can be complex. (The topic of dual diagnosis, mental illness and substance abuse, is given more thorough treatment in chapter 8.) Depending on the severity and duration of the person's disabilities, the family may have expended considerable emotional and financial resources in coping with the situation. All areas of family functioning may be affected by the presence of a dual diagnosis in a family member, including the general atmosphere, the ways family members communicate with each other, and the relationships, roles, and responsibilities that family members assume or are assigned (Daley, Moss, & Campbell, 1993). Likewise, families affect the family member with a disability. In their attempts to control the uncontrollable, some family members may become overinvolved or enmeshed. Others become completely shut off or disengaged...

Overview Of Empowerment Intervention

The intervention was designed to achieve the following objectives (1) to increase positive perceptions of self, (2) to increase goal-setting behavior, (3) to increase the perception of control in one's life and to learn to distinguish between what one can and cannot control, (4) to improve participants' self-efficacy beliefs, and (5) to increase the recognition and utilization of adaptive coping strategies for achieving desired outcomes. The objectives and tasks used to meet the objectives were interrelated in that improvements in one area were expected to relate to improvements in other areas. For example, goal setting should increase one's self-efficacy beliefs and utilization of adaptive coping strategies. African Americans who participated in the intervention had varied disabilities, including physical, chronic illness, substance abuse, and cognitive disabilities (among others).

Major Issues And Directions For Future Research Toward A Clinical Neuropsychology Of Prospective Memory

Include other brain diseases (e.g., Alzheimer's disease, Parkinson's disease, multiple sclerosis), psychiatric disorders (e.g., schizophrenia, depression), substance abuse (e.g., alcohol, cannabis, MDMA), viral infections (e.g., HIV and Herpes Simplex Encephalitis), and developmental disorders (e.g., ADHD, autism). The patient groups were chosen in these studies mainly because they were reported to have prospective memory problems or because their pathology is related to brain areas that are supposed to be related to prospective memory. Most of these studies compared the performance of clinical groups and matched controls on one or more types of prospective memory (e.g., time-, event-, or activity-based) using tasks developed in the experimental literature. Typically, the results of these studies indicate that these patients tend to be impaired on one or more types of prospective memory (refer to Table 13.1).

Are Peer Delivered Services Better than Other Services

Peer providers were more effective in achieving positive gains in terms of a number of quality-of-life measures including greater satisfaction with housing and financial situation, fewer life problems, and reduced substance abuse among the consumers served (Felton et al., 1995 Klein et al., 1998). Kaufman (1995) examined the outcomes of a peer partnership employment program and found that those assigned to the program achieved superior vocational outcomes when compared to recipients of traditional vocational rehabilitation services. Craig, Doherty, Jamieson-Craig, Boocock, and Attafua (2004) compared two assertive outreach teams that provided case management to a group of high-risk individuals. One of the teams employed peer providers. They found that the consumers who received peer-provided services were better engaged with the team, participated more

The History of the Self Help Movement

Throughout the 1980s federal funding supported the expansion of self-help initiatives throughout the United States. The Substance Abuse and Mental Health Services Administration's Center for Mental Health Services' (SAMHSA CMHS') Community Support Program provided technical assistance to a number of consumer-run programs and also funded various demonstration projects in order to promote the development of self-help groups and other innovative peer support programs (Brown & Parrish, 1995 Schmidt, 2005 Van Tosh & Del Vecchio, 2000). State mental health authorities also began to support the development of self-help initiatives. For example, in the early 1980s, the New Jersey Division of Mental Health Services provided funding needed to open and operate drop-in centers, now called self-help centers, throughout the State (Barrett, Pratt, Basto, & Gill, 2000). Self-help centers are alternative programs that offer a variety of mutual support, social, and advocacy activities. Based on the...

The Severe Mental Illnesses

Today, there is increasing awareness that people who experience severe mental illness often suffer from other serious maladies as well. These dually diagnosed individuals may be coping with substance abuse problems, developmental disabilities, severe learning disabilities, and chronic physical illnesses at the same time they are struggling with their mental illness. As you might imagine, the problems raised when someone is suffering from more than one disorder at the same time can be very difficult. Which disorder should be treated first Does the treatment of one disorder negatively affect the treatment of another disorder Which disorder is causing the symptoms that are present Special programs for people who are dually diagnosed are increasing

Evaluation Of The Kidney Transplant Recipient 411 General Indications

Once the irreversibility of the process is clear, patients must be free of active infection (acute or chronic), active inflammatory glomerulonephritis (such as in active systemic lupus erythematosus SLE ), active uncontrolled psychiatric disorder, and untreated malignancy). In addition, the patient must have a reasonable life expectancy after transplant and must be physiologically able to tolerate the transplant procedure. ESRD patients are prone to develop sequelae of arteriosclerosis and coronary artery disease (CAD), due in part to the higher incidence of hypertension and DM. The workup outlined here should also aim at excluding the consequences of other end-organ damage from these causes. High levels of sensitization to donor tissues also precludes transplantation due to a high incidence of hyperacute rejection and graft loss. This is further explained later in this chapter. Finally, patients must be compliant, without active addiction (alcohol and or...

The Risk Of Alienation Of Community Mental Health Services From The General Health Care System

It is not yet clear whether the closure of all mental hospitals for the care of the chronically ill will have only favourable effects. Recently, Munk-j0rgensen 64 showed, based on the National Danish Case Register data, that parallel to the decrease in psychiatric beds in Denmark from 1.6 1000 in 1980 to 0.76 1000 in 1998 the rates for crime and suicide among the non-hospitalized mentally ill compared with the general population increased steadily and considerably in Denmark. Several recent large-scale epidemi-ological studies of the risk of violence among the mentally ill have consistently demonstrated that an increased percentage of alcohol and substance abuse and deficits in psychopharmacological treatment and individual care increase the risk of violence among the discharged mentally ill patients 6568 . Munk-j0rgensen 64 concludes that the closing down of mental hospitals has brought significant improvement for the majority of patients at the expense of deteriorated conditions for...

Limitations on the Research Evidence

Though the evidence cited in the literature has tended to support the effectiveness of IDDT, questions have been raised about the validity of the research studies. One important source that has questioned the validity of IDDT comes from the Cochrane Review. First becoming widespread in the 1990s, Cochrane reviews focus on specific medical specialties or subspecialties, systematically gathering all relevant data generated from controlled clinical trials. Named for one of the earliest proponents of this idea, Professor Archibald L. Cochrane, the reviews are commissioned by the Cochrane Collaboration (http www. Formed in 1993, the collaboration which is based in Oxford, England, currently has 10,000 collaborators from more than 80 countries around the world. A number of Cochrane reviews have focused on treatment and rehabilitation services for severe mental illness, including the issue of integrated treatment for persons with severe mental illness who are substance...

Functional Assessment of PTSD

A thorough Substance Abuse assessment should be included in the PTSD evaluation. Ruling in or ruling out Substance Disorders will help in all phases of patient interaction, diagnosis, treatment, and follow up. Instruments of particular use are the Addiction Severity Index, the Michigan Alcohol Screening Test, or the Drug Abuse Screening Test.

Peer Operated Services

Peer support and mentoring programs emphasize one-to-one relationships, and outreach to consumers in their homes or in other natural community settings. The Friends Connection in Philadelphia, Pennsylvania, targets individuals who are coping with both a mental illness and substance abuse disorder. Consumers are matched with peer support providers who visit them regularly and help them identify and achieve recovery-oriented goals. Group social and recreational activities are also provided to help consumers decrease their isolation and build a supportive social network (Whitecraft et al., 2005).

Causes of Eating Disorders

Studies suggest a genetic predisposition to eating disorders, particularly in those persons who engage in binge eating and purging behaviors. Their family histories typically include higher than expected numbers of persons with mood disorders and substance abuse problems. Dysfunctions in the pathways for the substances that transmit messages in the brain, the neuro-transmitters, are thought to play a role in the development and maintenance of eating disorders, although these dysfunctions are not sufficient to explain the entire problem by themselves. The psychological theories about the causes of eating disorders postulate that individuals with underlying feelings of powerlessness or personal inadequacy attempt to cope by becoming preoccupied with their body's shape and size. Finally, the incidence of sexual abuse is higher among persons with eating disorders, particularly bulimia nervosa, than among those in the general population.

Effects of Drugs and Natural Reinforcers

Many people commonly take stimulant drugs like nicotine, amphetamine, cocaine, or depressant drugs like morphine or alcohol, all of which affect behavior and are thus said to be psychoactive. The long-term consequences of abusing psychoactive drugs are now well-documented, and it has been hypothesized that some of the behavioral symptoms observed in drug addicts or alcoholics are related to abnormalities in the functioning of the prefrontal regions (Robbins and Everitt, 2002). One experimental demonstration of

Practice of cognitive therapy

To meet these objectives, the cognitive therapist will set an agenda for the session perform a mood check, which is usually done by administering the BDI review the presenting problem with the patient and obtain an update covering the time period since the initial evaluation educate the patient about cognitive therapy and his or her diagnosis assign homework for the next session summarize the session and ask the patient for feedback. If the use of medications and or substance abuse are issues for the patient, these are also placed on the agenda of the initial session.

Full Support Model Assertive Community Treatment Model

Or no emphasis on referring clients to other existing community services. In other words, case managers utilizing the full support model are providing basic case management services plus a variety of rehabilitative and treatment services with a multidisciplinary team that typically includes a psychiatrist, nurse, rehabilitation counselor, substance abuse counselor, and perhaps a peer case manager. This team is composed of specialists from different service areas and is employed to ensure that clients have everything they need to make a good adjustment in the community.

Beyond Self Help Categories of Peer Provided Services

Self-help groups are just one way that persons who have severe mental illnesses help others who are coping with similar challenges. There are also other categories of peer-delivered services, which have been defined as services provided by individuals who identify themselves as having a mental illness who are specifically employed to help other consumers (Solomon, 2004 Solomon & Draine, 2001). Almost from its inception, the field of substance abuse counseling recognized the benefits of utilizing individuals recovering from alcoholism and other substance abuse disorders as regular service providers (Moxley & Mowbray, 1997). An obvious benefit of this strategy is the ability of an individual who is in recovery to truly empathize with the experiences of the persons to whom he or she is providing services. Providers who share the experience of coping with a similar illness or disability may also have an advantage over other professional providers in the length of time it takes to...

Assertive Community Treatment An Evidence Based Practice

Assertive community treatment is one of the most widely utilized evidence-based practices (EBP). As this chapter has pointed out, ACT has many positive characteristics for both the consumer and the service delivery system. Essentially, comprehensive services including medication, counseling, case management, rehabilitation, substance abuse services, and other specialized supports are provided to the consumer in the environments of his or her choice.

The Implications Of Dual Diagnosis For Community Mental Health Services

An increasing number of people are given a dual diagnosis of severe mental illness and substance misuse. The prevalence of substance abuse in most US community samples of individuals with psychotic illnesses falls between 30 and 50 112 . The frequency of dual diagnosis in other countries is likely to vary, mainly in response to different cultural attitudes to substances of potential abuse. Dual diagnosis is associated with greater inpatient service use, poorer adherence to treatment, more frequent violent behaviour and probably more severe clinical and social problems than psychotic illness alone 113,114 . However, various impediments to effective care may arise with each of these strategies 116, 117 . Thus, workers in the CMHTs may lack training, experience and confidence in helping people with addictions. Staff responses may be punitive rather than therapeutic, with the substance abuse conceptualized as difficult behaviour rather than as a disabling problem for which treatment is...

Principal Publications

Cognitive Therapy of Substance Abuse. New York Guilford Press, 1993. Extension of cognitive therapy Beck was cautious in extending his cognitive model of depression to other mental disorders he has always been a methodical researcher, careful to restrict his claims to demonstrable results. For example, his first book on the treatment of depression recommended limiting cognitive therapy to nonpsychotic patients with unipolar depression who had not responded to or refused to take antidepressant medication. After the 1970s, however, the cognitive model was successfully applied by Beck's followers to a wide range of problems, including anxiety disorders, substance abuse, marital conflict, eating disorders, and anger management. One study reported that the interest in cognitive therapy among mental health care professionals increased 600 in the 16 years between 1973 and 1989. In the 1990s, cognitive therapists published outcome studies that reported success in treating psychotic...

Elements of the Evidence Based Practice Integrated Dual Disorder Treatment

Well a program resembles the IDDT model, the IDDT Fidelity Scale was developed. (This scale can be downloaded from the Substance Abuse and Mental Health Services Administration website at Some of the items on the IDDT Fidelity Scale include the following 2. Assertive outreach Actively seeking out clients in their own environments, assertive outreach is an element of many of the EBPs. Given the propensity of individuals with either mental illness or substance abuse disorders to drop out of treatment, assertive outreach is often necessary to maintain contact. 4. Reduction in negative consequences (harm reduction) In general, the idea is that the focus should be on reducing the harm or negative consequences of substance use rather than insisting on abstinence. In short, if a client can be helped, for example, to drink less or less frequently the harm caused may be reduced. This is a controversial issue in the substance abuse community where abstinence has been considered the gold...

Medication Compliance

Another factor consistently associated with decreased medication compliance is substance abuse (Heyscue, Levin, & Merrick, 1998). Some individuals discontinue medication when drinking alcohol or abusing substances. Some of these individuals also take to self-medicating with both legal prescription drugs and illicit drugs on a dosage and schedule they choose. This is discussed in more detail in Chapter 8, which addresses dual diagnoses.

Designing an Ideal Residential Services Program

Illness and are currently at high risk for psychiatric hospitalization and or homelessness. Thus, you can assume that the people you will be providing services for have had a great deal of difficulty residing in the community because they are psychiatrically unstable, have severe functional deficits, have other issues such as problems with substance abuse, or most likely some combination of these. Your task is to determine what type of residential services you want to provide and provide a clear rationale for your choices. Consider the following questions

Why Do Some Develop PTSD and Some Do

The personality trait of sensation seeking has been implicated in increased exposure risk. Zuckerman et al. (1979) define sensation seeking as the need for varied, novel, and complex sensations and experiences and the willingness to take physical and social risk for such experiences. This has been associated with Substance Abuse, which itself is an exposure risk factor. The personality traits of Extroversion and Neuroticism are exposure risk factors (Breslau, Davis, & Andreski, 1995). McNally (2003) states, outgoing, stress prone people were exposed to trauma more often than retiring, calm people.

Substance Use Disorder Research

Laboratory studies of the biological bases of substance abuse and dependence involve clinical (human) and preclinical (animal) approaches. Such research has demonstrated that there are areas of the brain that can provide powerful feelings of euphoria when stimulated, indicating that the brain is primed for the experience of pleasure. Direct electrical stimulation of some areas of the brain, including an area first referred to as the medial forebrain bundle, produced such strong addictive behaviors in animals that they ignored many basic drives including those for food, water, mating, and care of offspring.

Substance Use Disorders

Psychopathology stress Fields of study Biological treatments coping critical issues in stress motivation theory nervous system stress and illness substance abuse Substance use disorders include the formal medical diagnoses of substance abuse and substance dependence for many types of drugs of abuse, including alcohol and prescription drugs. These disorders are characterized by recurrent problems in everyday life or physical or emotional distress and impairment that are caused or exacerbated by the use of the substances of abuse.

Dual Diagnosis

The term dual diagnosis refers to the presence of two coexisting conditions. The two dual diagnoses most often encountered in PsyR services are mental illness and substance abuse (i.e., drug or alcohol) and mental illness and developmental disability. In both cases, the presence of a dual diagnosis has historically been a complicating factor in receiving adequate and appropriate services. Mental health providers often knew little about drug abuse or developmental disability and may have either declined to provide services to someone with a dual diagnosis or provided mental health services without addressing the coexisting disability. Similarly, substance abuse service providers and developmental disability service providers often either addressed only the issues with which they were familiar or declined to provide services altogether. Recently the presence of coexisting conditions, and the ways in which those conditions affect each other, have received greater attention. Advances in...

Anorexia Nervosa

As the weight loss in either type reaches starvation proportions, anorexics become more and more preoccupied with food they may hoard food or steal. They also experience sleep abnormalities, loss of interest in sex, and poor concentration and attention. In addition, they slowly restrict their social contacts and become more and more socially isolated. In general, anorexics of the binge-eating purging type are likely to have problems with impulse control and may engage in substance abuse, excessive spending, sexual promiscuity, and other forms of compulsive behavior. This group is

Evolution into ACT

Training in Community Living has evolved into assertive community treatment. Over the years, principles for the implementation of ACT have been established and its critical ingredients have been established. These have been outlined by Phillips et al. (2001) and Bond, Drake, Mueser, and Latimer (2001). ACT employs a multidisciplinary team approach with the capacity to provide services 24 hours per day, 7 days a week when needed. The team approach ensures that someone with knowledge of each individual receiving services is always available if needed. In addition, caseload sizes are kept small (approximate ratio of one ACT team member to 10 consumers). So a multidisciplinary team of six would serve a caseload of 60. All treatment and rehabilitation services are provided by the team including a part-time psychiatrist, nurse, case manager, substance abuse counselor, vocational specialist, and sometimes a peer consumer provider. The team meets four or five times a week and is led by a team...

Sequential Services

Traditionally, mental health treatment consists of psychotropic medication (Chapter 3), individual and or group counseling, perhaps day program services (Chapter 6), and case management services (Chapter 7), which are typically used for persons with severe and persistent mental illness. Traditional substance abuse treatment often requires abstinence (refraining from the use of all drugs), sometimes including abstinence from psychotropic medication, attendance at Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings, and working a 12-step process based on the AA 12-step model (Evans & Sullivan, 1990). A popular misconception on the part of mental health providers has contributed to this method of treatment. Many providers believe that people with mental illness engage in substance use solely as an attempt to self-medicate. In other words, drugs or alcohol are used to provide relief from their psychiatric symptoms. If this is the case, it follows that adequate treatment of the...

Parallel Services

In the absence of specialized knowledge and training, the mental health provider lacks an understanding of the addictive behavior, while the addictions specialist lacks an understanding of mental illness. Furthermore, the traditional treatments used in each of these approaches tend to contradict each other. Mental health treatment often emphasizes empathy toward the individual and the development of a trusting working relationship. This empathic counseling is used to assist the person to gain insight and to set and achieve goals. Substance abuse treatment tends to take a more confrontational, no-nonsense stance toward the client. An individual's failure to do follow through on substance abuse treatment is typically seen as a lack of commitment and confronted by the counselor or group members. This approach is in stark contrast to mental health services, which employ active outreach to engage clients in services when they might drop out of treatment. The person with a dual disorder...

Integrated Services

The integrated approach favored today was developed to overcome the shortcomings of the sequential and parallel approaches. Research literature surveys (e.g., Ridgely, Goldman, & Willenbring, 1990) supported the notion that parallel or sequential services are less effective than an integrated approach. With integrated services, the person with both a substance abuse disorder and a psychiatric illness receives treatment for both disorders in the same place, at the same time, by the same practitioners. These practitioners are knowledgeable about both disorders as well as about the complications resulting from co-occurring disorders. Early efforts at integrating mental health and substance abuse services added substance abuse groups into mental health day treatment. These groups often followed the 12-step model adhering to features such as confrontation and the focus on abstinence. Still, practitioners found that some group members, who were often at different stages with regard to their...


In this stage individuals are weighing the benefits and costs of their behavior against the benefits and costs of change. They will move toward change when they perceive that the benefits of changing outweigh the costs of change, or the costs associated with their behavior outweigh its benefits. Thus, the treatment task at this stage is to help the individual understand that the benefits of change outweigh the benefits of continued substance abuse. This may also be accomplished by reinforcing or increasing the benefits of change, for example, by getting a job or acquiring new friends.

Clinical Features

Often associated with mood disorders, substance abuse, and generalized anxiety disorder III. Differential Diagnosis Sleep deprivation, primary hypersomnia, breathing-related disorders, hypersomnia associated with mental disorder such as depression or substance abuse, medical condition


The personality disorders have been the subject of criticism by researchers because of the difficulty in diagnosing them reliably. Individuals with a personality disorder often display symptoms of other personality disorders. For example, researchers have debated about the distinction between schizoid personality disorder and avoidant personality disorder, as both disorders are characterized by an extreme in social isolation. Individuals with personality disorders are more likely than the general population to suffer from other psychological disorders, such as depression, bulimia, or substance abuse. This overlap of symptoms may lead to difficulty with diagnostic reliability. The personality disorders occur so frequently with other types of psychological disorders that it is challenging to sort through symptoms to determine what is evidence of each disorder. It is difficult to estimate the prevalence of personality disorders in the United States, as individuals with these disorders do...

Mid Phase

Children may have some additional problems due to the loss of parents or other changes within home and family. Separation anxiety, reversal of roles, bed-wetting, phobic disorders, substance abuse and behavioural problems may be present in addition to depression, anxiety, PTSD and psychotic illnesses.


Substance use is studied in psychology from personality, social, and biological perspectives. Social and personality studies of individuals with substance use disorders have produced a variety of theories. These theories have focused on issues such as difficulties people might have with tolerating stress, being unable to delay gratification, developing social skills, being socially isolated or marginalized, being attracted to taking risks, and having difficulties regulating one's own behavior. Additionally, environmental issues, such as poverty or high levels of stress, have been linked to substance use problems. Biological theories of these disorders suggest that genetic and conditioned sensitivities to substances of abuse and their effects may predispose individuals to acquire these disorders. For instance, people who have increased needs to seek relief from pain or have an increased need to seek pleasure or euphoria might be at greater risk for developing such problems. Pain is...

Future Possibilities

Future research on substance use disorders is likely to focus on biological determinants of the problem for the purposes of prevention and treatment, environmental circumstances related to problem development, the interaction of culture and gender as they relate to substance use disorders and treatments, and how other mental illnesses can compound problems related to substance use. Many people erroneously consider biological explanations of problematic behaviors to be an excuse for such behaviors. In fact, discoveries regarding the neural contributions to such behaviors are the basis on which rational therapies for such behaviors can be developed. Recognizing that a disorder has a basis in the brain can enable therapists to address the disorder with a better armamentarium of useful therapeutic tools. In this way, simple management of such disorders can be replaced by real solutions to the problems created by substance abuse.

Rogers Story

Roger's story has some similarities with many of the homeless persons you might encounter on the streets of big cities. With a mental illness and co-occurring substance abuse problems, Roger has had a lifetime of difficulty understanding his conditions and trying to fit into society. While some people seem to get all the breaks, others, like Roger, seem born under a dark cloud. As you read about Roger you might consider whether his life to date would have turned out the same had he been born at a later date. You should also be considering the following questions Roger is a 45-year-old man with a dual diagnosis of bipolar disorder and substance abuse disorder. He jokes that he's recovering from substance abuse and the system, meaning the school system, the foster care system, and the legal system. As a child he moved from one foster home to another. Roger's school performance was generally mediocre. He occasionally did well on tests or assignments but more often barely passed. Most The...

The Role of Stress

Stress Etiology

Episodes of the illness can be triggered by various stressors, many of which may appear to be normal in their intensity, but which can lead to the catastrophic symptoms and events of mental illness. Stressors that have the potential to bring on an acute episode include personal losses, developmental transitions, and stressful life events such as marriage, graduation, and moving. Physical illness, injury, substance abuse, and other physiological factors such as sleep deprivation have also been associated with the onset of psychiatric symptoms. Even in the absence of a time-limited stressor, vulnerable individuals can succumb to ambient levels of challenge, tension, or conflict in their environment . . . (Anthony & Liberman, 1986 pp. 542-543).

Housing First

Very much in line with PsyR values and principles, the Housing First strategy is based on consumer choice and harm reduction (see Chapter 8). As with supported employment, consumers are assisted in getting into housing of their choice first, not having to overcome unrelated prerequisites or obstacles first. For example, unlike many other residential services, Housing First does not require persons with a dual diagnosis of mental illness and substance abuse disorder to be substance free before obtaining housing. Instead, housing is obtained as soon as possible and then services are provided to deal with the mental illness and substance abuse. Tsemberis, Gulcur, and Nakae (2004) tested the housing first strategy by randomly assigning 225 persons with a dual diagnosis to either receive housing contingent on prerequisites (e.g., sobriety) or receive housing without prerequisites. After 2 years it was determined that there were no differences in level of substance abuse between the two...


Area of mental health diagnoses, but social workers, educational counselors, substance abuse counselors, criminal justice workers, social service professionals, and those who work with the developmentally disabled also gather mental health diagnostic information and use it in their work.

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