Dual Diagnosis – Alcoholism and Psychiatric Disorders

Alcoholism is a chronic condition in which the individual is unable to refrain from the frequent consumption of alcohol in quantities sufficient to cause intoxication. The inability to refrain or the lost of control may be manifested in two ways. The individual may be unable to let a day go by without drinking heavily. On the other hand, he may have periods of sobriety between episodes of heavy and prolonged drinking, but once he begins to drink again he is unable to stop until he had drunk himself into unconsciousness. Both patterns are sometimes found in the same individual, but usually only one is present.
 
However, it should be noted, heavy and prolonged drinking does not in itself constitute alcoholism. There are many individuals who drink heavily and consistently to gratify a psychological need. They use alcohol as a crutch and cannot function well without it. Still there are times when they are able to reduce or even discontinue their alcohol intake without serious disturbance. In other words, these individuals are not addicted.
 
A major challenge for mental health and substance abuse professionals is the client who has both alcoholism and a coexisting psychiatric disorder. Clients with dual diagnoses are often seen by both the chemical dependency and psychiatric treatment communities. Some research suggests upward of 70 percent of hospitalized alcoholics have experienced one or more episodes of another substance abuse or psychiatric diagnosis in their lifetime.
 
Too often it is difficult to determine whether psychiatric problems in alcoholics are the result or consequence of alcoholism. There is evidence which supports each of these positions. It is not always easy to determine if dual diagnoses exist in a client. In some instances a psychiatric disorder will mask a psychiatric disorder. Once the deal diagnoses are established, it is not always clear which problem to treat first. Some experts believe that the psychiatric problem should be stabilized first, while others take the position that the alcoholism is the central problem and should be treated first. Both positions may be correct in different situations. For example, untreated alcoholism may contribute to relapse with the psychiatric disorder and an untreated psychiatric disorder may impact on relapse with the alcoholic client.
 
There is growing evidence that there is a genetic or biological predisposition to the development of alcoholism. Alcoholism alone may run in families, or it may be seen together with a family history of suicide or manic-depressive disorder. In some instance, alcohol may, in fact, be used to self-medicate anxiety, an affective disorder, or a schizophrenic disorder.
 
Professionals working in this area should remember that alcoholism is not a distinct disease, but a disease condition found in association with many different psychiatric disorders including various psychoses, psychoneuroses, and personality disorders. It is a condition reached by many different paths, and many different types of emotional disturbance working in combination with life stresses to which the individual is particularly vulnerable.
  
Contrast to common belief, there is no single alcoholic personality especially prone to the development of alcoholism. There are, however, many different kinds of disturbed personality that need and pursue the effects produced by alcohol. Ultimately, as a result of prolonged alcoholism, there emerges a characteristic alcoholic personality highlighted by mental, emotional, and moral deterioration. This is an end product and not a pre-existing condition.
 
Take impulsivity, for example, which is a problem for many different types of personality and psychiatric disorders, especially alcoholism. A recent study was completed that examined impulsivity among alcoholics and found that the inability to postpone immediate gratification could be a vulnerability marker for alcoholism. The same study found that certain impulse-control may be specific to antisocial and borderline personality disorders and that around 50 percent of alcoholic patients with psychiatric disorders including pathological impulsivity.
 
The author of this study, Gabriel Rubio, associate professor at Complutense University of Madrid, Spain concluded that few studies have examined impulsivity within different alcoholic subpopulations, which could have important treatment and relapses implications. The two most frequent personality disorders found in alcoholic samples are borderline and antisocial personality disorders. Furthermore, according to Rubio, “We do not know if impulsivity found in alcoholics is due to a specific trait typical of alcoholism or is due to co-morbidity with cluster B personality disorders.”
 
Rubio and his colleagues examined two groups: 247 alcoholic men from two alcohol-treatment centers, and 96 non-substance-abusing men from the community of matching age and education. The study measured inhibitory control, and assessed sustained attention, rapid-response impulsivity, and ability to delay reward, for all participants.
 
The final results indicated that alcoholics without cluster B personality disorder displayed a greater inability to delay gratification than control healthy subjects. Rubio said. “This means that a subject prefers a smaller but sooner expected value, such as a drink right now, over a later but larger expected value, such as increases in health or psychological condition. We can hypothesize that this subject will relapse very quickly.
 
The second finding involved alcoholics with cluster B personality disorders, who displayed more impairment on inhibitory control. “This means that a subject has problems with appropriately inhibiting thoughts or actions,” said Rubio. “In other words, when an action has begun, such as drinking that first drink, he or she will have difficulties stopping, meaning he or she cannot stop drinking.”
 
Rubio concluded that these finding suggest that previous perception of alcoholism and impulsive behavioral may need to be reconsidered. “High levels of behavioral impulsivity may be related to other disorders, such as borderline and antisocial personality disorders, which are frequently present in subsets of alcoholics,” he said.
 
According to Rubio finding; “We may also need to rethink treatment options. Programs that emphasize immediate rewards for abstinence may have greater opportunity of succeeding with antisocial personality disorder. Conversely, psychotherapeutic and pharmacological interventions that focus on behavioral control may work better with subjects having borderline personality disorders.
 
People struggling with mental illness and chemical dependency attention should be given to finding support groups for individuals with dual disorders that can serve to reinforce important issues such as opportunities to socialize, having access to recreational activities, and developing peer relationships. Attendance in groups that deal with education and awareness of dual diagnosis issues, medication management, life skills, and improvement in activities of daily living is most helpful.
 
Reference: Alcoholism: Clinical & Experimental Research Impulsivity May Especially Vex Alcoholics With Antisocial And Borderline Personality Disorders. http://www.sciencedaily.com