Chapter 8Psychotic Disorders

This chapter is an overview of current assessment and treatment principles for patients with alcohol and other drug (AOD) use disorders and psychosis. Along with an increased awareness of the treatment needs of patients with these dual disorders, an increased emphasis on service systems has evolved. These and other forces have prompted the need to reassess traditional models and service approaches to develop assessment and treatment strategies that meet the specific needs of patients with AOD use disorders and psychosis.

All too often, AOD use disorders are undetected in patients with psychotic disorders, and traditional treatment approaches are often inadequate. For example, attempts have been made to treat psychotic and AOD use disorders in a sequential manner, treating one disorder first and then the other. While a single-focus approach is helpful for differential diagnosis, and is effective in treating some patients, it is frequently unsuccessful for patients with AOD problems who have severe and recurrent psychotic episodes. This chapter provides an overview of a dual-focus approach to the assessment and treatment of patients with these dual disorders. A single-focus approach emphasizes the importance of developing a diagnosis and subsequent treatment plan -- such as is done when treating patients who have a single disorder. In a dual-focus approach, the emphasis is not on making a diagnosis, but rather on 1) the severity of presenting symptoms, 2) crisis intervention and crisis management, 3) stabilization, and 4) diagnostic efforts within the context of multiple-contact, longitudinal treatment. By concentrating on symptoms, crisis management, and stabilization, clinicians can simultaneously focus on patients' treatment needs that are caused by both the psychotic and AOD use disorders, rather than focusing on one disorder or the other.

Dual-Focus Approach for Assessing and Treating Patients with Dual Disorders

• Initial focus on severity of presenting symptoms, not on diagnosis of one disorder or another
• Acute crisis intervention and crisis management
• Acute, subacute, and long-term stabilization of patient
• Ongoing diagnostic efforts
• Multiple-contact longitudinal treatment.

The term psychosis describes a disintegration of the thinking process, involving the inability to distinguish external reality from internal fantasy. The characteristic deficit in psychosis is the inability to differentiate between information that originates from the external world and information that originates from the inner world of the mind (such as distortions of normal thinking processes) or the brain (such as abnormal sensations and hallucinations).

Psychosis is a common feature of schizophrenia. Psychotic symptoms are often a feature of organic mental disorders, mood disorders, schizophreniform disorder, schizoaffective disorder, delusional (paranoid) disorder, brief reactive psychosis, induced psychotic disorder, and atypical psychosis.

Schizophrenia is best understood as a group of disorders with similar clinical profiles, invariably including thought disturbances in a clear sensorium and often with characteristic symptoms such as hallucinations, delusions, bizarre behavior, and deterioration in the general level of functioning.

Severe disturbances occur with relation to language and communication, content of thought, perceptions, affect, sense of self, volition, relationship to the external world, and motor behavior. Symptoms may include bizarre delusions, prominent hallucinations, incoherence, flat affect, avolition, and anhedonia. Functioning is impaired in interpersonal, academic, or occupational relations and self-care.

Schizophrenia can be divided into subtypes: 1) in the paranoid type, delusions or hallucinations predominate; 2) in the disorganized type, speech and behavior problems predominate; 3) in the catatonic type, catalepsy or stupor, extreme agitation, extreme negativism or mutism, peculiarities of voluntary movement or stereotyped movements predominate; 4) in the undifferentiated type, no single clinical presentation predominates; and 5) in the residual type, prominent psychotic symptoms no longer predominate. The diagnosis of schizophrenia requires a minimum of 6 months' duration of symptoms, with active psychotic symptoms for 1 week (unless successfully treated).

Clinicians generally divide the symptoms of schizophrenia into two types: positive and negative symptoms. Acute course schizophrenia is characterized by positive symptoms, such as hallucinations, delusions, excitement, and disorganized speech; motor manifestations such as agitated behavior or catatonia; relatively minor thought disturbances; and a positive response to neuroleptic medication.

Chronic course schizophrenia is characterized by negative symptoms, such as anhedonia, apathy, flat affect, social isolation, and socially deviant behavior; conspicuous thought disturbances; evidence of cerebral atrophy; and generally poor response to neuroleptics. In general, acute substance-induced psychotic symptoms tend to be positive symptoms. .

Schizophreniform disorder is a condition exhibiting the same symptoms of schizophrenia but marked by a sudden onset with resolution in 2 weeks to 6 months. Some patients exhibit a single psychotic episode only; others may have repeated episodes separated by varying durations of time.

Schizoaffective disorder is a condition that includes persistent delusions, auditory hallucinations, or formal thought disorder consistent with the acute phase of schizophrenia, but the condition is also frequently accompanied by prominent manic or depressive symptoms. Schizoaffective disorder is further divided into bipolar (history of mania) and unipolar (depression only) types. .

Delusional disorders are characterized by prominent well-organized delusions and by the relative absence of hallucinations; disorganized thought and behavior; and abnormal affect. The delusional disorders are divided into six types: persecutory, grandiose, erotomanic, jealous, somatic, and unspecified.

Brief reactive psychosis describes a condition in which an individual develops psychotic symptoms after being confronted by overwhelming stress. The onset of symptoms is abrupt, without the gradual symptom development often seen in schizophrenia or schizophreniform disorder, and the duration is brief (no longer than 1 month). .

Induced psychotic disorder describes a disorder characterized by the uncritical acceptance by one person of the delusional beliefs of another. In other words, a dominant partner has a delusional psychosis that is believed and accepted by a passive partner.

AOD-induced psychotic disorders are conditions characterized by prominent delusions or hallucinations that develop during or following psychoactive drug use and cause significant distress or impairment in social or occupational functioning. This disorder does not include hallucinations caused by hallucinogens in the context of intact reality testing.

Although there can be great variability in individual susceptibility to AOD-induced psychotic symptoms, it is important for the clinician to determine if the presenting symptoms could plausibly be induced by the type and amount of drug apparently consumed. For example, vivid auditory, visual, and tactile hallucinations are plausible side effects of a 5-day, high-dose cocaine binge. However, should these symptoms emerge during a brief episode of mild alcohol intoxication, it is likely that the symptoms represent an underlying psychotic process that has been exacerbated by the use of alcohol.

Psychotic symptoms induced by stimulant intoxication are unusual when stimulants are used in low doses and for brief periods. Acute stimulant intoxication in the context of a chronic, high-dose pattern can cause symptoms of psychosis, especially if coupled with a lack of sleep and food and environmental stressors. Stimulant-induced psychotic symptoms can mimic a variety of psychotic symptoms and disorders including delirium, delusions (often persecutory and paranoid), prominent hallucinations, incoherence, and loosening of associations. Stimulant delirium often includes formication, a tactile hallucination of bugs crawling on or under the skin.

Particularly when unmedicated, sedative-hypnotic withdrawal can include symptoms of psychosis. Acute withdrawal from alcohol, barbiturates, and the benzodiazepines can produce a withdrawal delirium, especially if use was heavy and tolerance was high or if the patient has a concomitant physical illness. Hallucinations and delusions are common features of sedative-hypnotic withdrawal delirium.

Many psychedelic drugs, such as the amphetamine-related psychedelics (for example, MDMA and MDA), are not hallucinogenic at the lower doses associated with situational psychedelic drug use. However, in a chronic, high-dose pattern of use (which is rare), psychotic symptoms are possible, by virtue of the drugs' stimulant properties. Other psychedelic drugs, such as LSD, have strong hallucinogenic properties.

Hallucinogen intoxication can cause hallucinogenic hallucinosis, characterized by perceptual distortions, maladaptive behavioral changes, and impaired judgment. Hallucinogen intoxication may also prompt hallucinogenic delusional disorder and a hallucinogenic mood disorder. However, hallucinogen-induced perceptual distortions such as hallucinations or visions are not considered evidence of psychosis when the drug user retains reality testing and is aware that the distortions are drug induced. Acute marijuana intoxication can produce a delusional disorder that may include persecutory delusions, depersonalization, and emotional lability. Similarly, acute PCP intoxication can lead to delirium, delusions, or a PCP-induced mood disorder.

Various studies have noted that the lifetime prevalence rate for schizophrenia is roughly 1 percent among the general population (Africa and Schwartz, 1992). In the Epidemiologic Catchment Area (ECA) studies, the prevalence rate for schizophrenia and schizophreniform disorders combined were as follows: 1) 1-month prevalence rate: 0.7 percent; 2) 6-month prevalence rate: 0.9 percent; and 3) lifetime prevalence rate: 1.5 percent (Regier et al., 1988).

The ECA studies reported that the lifetime prevalence rate of schizophrenia was 1.5 percent, and the 6-month prevalence rate was 0. 8 percent. The lifetime and 6-month prevalence rates of schizophreniform disorder were both 0.1 percent (Regier et al., 1990).

Clinical observation of high rates of AOD use disorders among patients with schizophrenia were supported by the ECA studies. Among individuals identified as having a lifetime diagnosis of schizophrenia or schizophreniform disorder, 47 percent have met criteria for some form of an AOD use disorder. Indeed, the odds of having an AOD use disorder are 4.6 times greater for people with schizophrenia than the odds are for the rest of the population: the odds for alcohol use disorders are over three times higher, and the odds for other drug use disorders are six times higher (Regier et al., 1990).

One study noted that among patients with AOD use disorders, 7.4 percent had a lifetime diagnosis of schizophrenia; the 1-month prevalence rate was 4.0 percent (Ross et al., 1988), although other studies of persons in AOD abuse treatment found the prevalence of schizophrenia to be about the same as in the general population -- about 1 percent (Rounsaville et al., 1991). While patients with AOD use disorders may experience acute episodic psychotic symptoms, few meet the diagnostic criteria for schizophrenia if AOD-induced symptoms are excluded.

Among severely mentally ill outpatient treatment populations, AOD use disorders are common; often more than 50 percent have AOD use disorders, depending upon the treatment setting. Among patients being treated for psychiatric problems in acute settings such as inpatient hospitals, combined psychiatric and AOD use disorders are also common.

Among patients with combined psychotic and AOD use disorders, bizarre behavior and communication generally prompt a mental health referral. Thus, people with psychotic disorders usually receive services through the mental health system and are rarely treated in the typical addiction treatment program.

Lifetime Prevalence Rates

• Among the general population, 1 percent have a schizophrenic disorder.
• Among schizophrenic patients, 47 percent have an AOD use disorder.

The following three case examples can help to demonstrate the need for a dual-focus approach to treating patients with combined psychotic and AOD use disorders, or patients with psychotic symptoms and AOD use disorders.

Married for over 15 years, Martha was responsible for most of the duties related to raising four children and maintaining the home. In the past, she had been treated for an episode of postpartum psychosis. Until recently, she had not required any psychiatric medications or mental health services.

Her husband, a successful businessman, was the family's only source of financial support and was emotionally distant. While Martha believed that her husband was frequently out of town on business trips, he was actually nearby having an affair with a woman whom Martha had known for many years. One day, he abruptly informed Martha of the affair and moved out of the house.

During the next 3 days, Martha was intensely depressed and agitated. Her normally infrequent and low-dose alcohol use escalated as she attempted to diminish her agitation and insomnia. During this time, she ate and slept very little. She began to feel extremely guilty for even the smallest problem experienced by her four children. She felt burdened by what she called her "transgressions, faults, and sins." She expressed fears about being doomed to "eternal damnation." Loudly and inconsolably, she declared that she "had lost her soul" and would have to repent for the rest of her life. While being taken to a nearby clinic for evaluation, she passionately described a conspiracy by members of the Catholic Church to steal her soul.

In his inner-city neighborhood, Thomas is well known by the local medical clinic, AOD treatment program, and community mental health program. During the day, he spends much of his time walking around the neighborhood, frequently talking to himself or arguing with an unseen individual. He spends most of his evenings in the park in a wooded area away from other people, except in the winter when he sleeps in community-run shelters.

Thomas has a prominent scar in the center of his forehead. When asked about it, he describes in great detail his "third eye," and the fact that he can see into the future through the eye. When asked about his stated reluctance to live in an apartment, he describes an aversion to "electromagnetic fields" that drain his "life force" and make it difficult for him to "think about good things." For extended periods lasting several months, Thomas appears disheveled and agitated, and can be seen drinking heavily or using whatever drugs are available.

However, he also experiences prolonged periods during which he does not drink or use other drugs, appears well groomed, and exhibits less severe psychotic behavior. In general, Thomas is pleasant and well liked, although he is known to become hostile and potentially violent during periods when he uses AODs.

During a rock concert, Laura was brought by her boyfriend Morris to the paramedics at a first aid station in a large auditorium. Morris described Laura's gradual deterioration over a 1-hour period. At first, Laura displayed abrupt shifts in affect, giddy and laughing one moment and agitated and impulsive the next. Morris said that she began "talking crazy" and not making much sense. He also mentioned that Laura had brief bursts of absolute terror lasting a few seconds or minutes, during which he had to stop her from running away. Morris believed that she was responding to hallucinations. He said that Laura stopped speaking and appeared to have lost the ability to do so. Later, she had a hard time walking and tried to crawl away from Morris. By the time that the paramedics were able to examine her, Laura was rigid, immobile, mute, and unable to communicate with others. Later, Morris admitted that they had used some PCP.

As can be seen, Martha, Thomas, and Laura have very different long-term needs. Martha's brief reactive psychosis and depression may never recur, and the relationship between her alcohol use and psychiatric symptoms should be explored. Thomas's chronic psychosis and frequent AOD abuse episodes are intricately woven together and require combined treatment. Until Laura's boyfriend provided information about Laura's acute drug use, the reason for her psychotic episode was unclear.

These case examples are valuable to demonstrate how the absence of a dual-focus approach can lead to treatment failure. While Martha's psychotic episode was related to overwhelming stress, her alcohol use might be underemphasized in a traditional mental health setting. Doing so may obscure the possibility that her drinking severely deepened her depression, increased daytime agitation, and exacerbated the psychotic episode.

While Thomas has an ongoing psychosis and AOD abuse problems, focusing on only one set of these problems means that he bounces back and forth between the mental health and addiction treatment programs, depending upon his current symptoms. His involvement with the local medical clinic for treatment of physical injuries that are sustained during episodes of impaired thinking often complicates his already uncoordinated treatment.

While Laura's drug-induced psychosis may fade as the drug is eliminated from her body, the episode can be used as a point of entry into AOD abuse treatment. Also, her immediate needs will be the same irrespective of the cause of her psychotic episode.

As these case examples illustrate, patients who experience psychosis and AOD use problems are often highly symptomatic and may have multiple psychosocial and behavioral problems. It is common for patients with dual disorders to have undergone different approaches to treatment by different providers without long-term success. Furthermore, clarifying the diagnosis and "underlying disorder" is extremely complicated in the early phases of assessment. The first step in treatment of a person with a dual disorder is an assessment that addresses biological, psychological, and social issues.

A common difficulty that clinicians experience is determining whether psychotic symptoms represent a primary psychiatric disorder or are secondary to AOD use. However, in the early phase of assessment, the goal is to stabilize the crisis rather than to establish a final diagnosis. The final diagnosis is often best determined during a multiple-contact, longitudinal assessment process. All assessments include direct client interviews, collateral data, client observations, and a review of available documented history.

The initial step of every assessment is to determine whether the individual has an imminent life-threatening condition. There are three domains of high risk that require assessment: biological (or medical), psychological, and social. At any given time, one aspect of this biopsychosocial approach may be more urgent than the others.

With regard to medical or biological issues, the goal of assessment is to ensure that patients do not have life-threatening disorders such as AOD-induced toxic states or withdrawal, delirium tremens, or delirium. Also, patients may be exhibiting symptoms that represent an exacerbation of their underlying chronic mental illness. The symptoms may be due to an aggravation of medical problems such as neurological disorders (for example, brain hemorrhage, seizure disorder), infections (central nervous system infection, pneumonia, AIDS-related complications), and endocrine disorders (diabetes, hyperthyroidism). The presence of cognitive impairment (such as acute confusion, disorientation, or memory impairment), unusual hallucinations (such as visual, olfactory, or tactile), or signs of physical illness (such as fever, marked weight loss, or slurred speech) show a high risk for an acute medical illness. Patients who exhibit this degree of risk need to be immediately referred for a comprehensive medical assessment.

With regard to psychological issues, the primary goal must be an assessment of danger to self or others and other manifestations of violent or impulsive behavior. Patients with a dual disorder involving psychosis have a higher risk for self-destructive and violent behaviors. Patients should be assessed for plans, intents, and means of carrying out dangerous behaviors. Patients who are imminently suicidal, homicidal, or dangerous need to be in a secure setting for further assessment and treatment. In addition, some patients may have cognitive impairment related to their dual disorder and be unable to adequately care for basic needs.

With regard to social issues, the primary goal is to ensure that patients have access to minimal life supports and have their basic needs met. Patients with a dual disorder involving psychosis are particularly vulnerable to homelessness, housing instability, victimization, poor nutrition, and inadequate financial resources. Patients who lack basic supports may require aggressive crisis intervention, such as the provision of food and assistance with locating a safe shelter. Lack of these social supports can be life threatening and can worsen medical and psychiatric emergencies.

Biopsychosocial Assessment of High-Risk Conditions

• Biological risks: Assess for life-threatening medical problems
• Psychological risks: Assess for violent and impulsive behaviors
• Social risks: Assess basic needs and life supports.

To provide a thorough assessment of patients who are experiencing psychotic symptoms, it is important to directly question patients about the three domains of medical, psychological, and social safety.

In the absence of overwhelming medical and psychiatric crises, the clinician should ask patients a series of questions that relate to medical assessment. One example is: "Have you been diagnosed or hospitalized for any major medical disorders?" Similar questions should address the recent onset of significant medical symptoms, episodes of head trauma or loss of consciousness, prescribed and over-the-counter medications, recent changes in medications, the use of AODs, and nutritional and sleep needs.

In addition, the assessment of medical symptoms should include a thorough cognitive examination of patients' orientation, memory, concentration, language, and comprehension.

Psychological safety issues relate to self-destructive and violent behaviors or an inability to care for oneself. The clinician should ask direct questions about plans, means, and intent for violence. Plans include specificity of lethal methods, such as time and place. Means include implements such as medications, ropes, and guns. Intent refers to the desire or explicit goal to end either one's own or another's life.

In particular, patients should be asked about command hallucinations and delusions that direct the person to hurt him- or herself or another. Impaired judgment or cognition that may result in an increased likelihood of impulsive, destructive behaviors.

It is also important to ask patients about their past, and particularly recent, history of violent behaviors, since a history of suicidal and homicidal behaviors is the best predictor of current risk for such behaviors.

Assessing Psychological Safety

• Suicide plans, means, and intent
• Delusions and command hallucinations
• Impulsivity or impaired judgment or cognition
• History of suicidal or homicidal behaviors.

Patients should be asked direct questions about past and current access to basic needs such as food, shelter, money, medication, or clothing. Patients should be assessed for past and recent episodes of victimization and of exchanging sex for money, drugs, and shelter.

It is essential to rule out imminently life-threatening medical or AOD-induced emergencies which may be causing or contributing to the psychotic symptoms.

Once medical and AOD-induced emergencies have been addressed or ruled out, the focus of probing assessment questions should relate to the severity of presenting behaviors and symptoms rather than to whether symptoms are primary or secondary to AOD use. The focus should be on assessing the severity of the immediate symptoms. With the exception of life-threatening emergencies, the clarification of "primary versus secondary" is an important issue in working with patients who have a dual disorder involving psychosis, but such clarification requires multiple-contact, longitudinal diagnostic differentiation.

Examples of key probing questions for delusions include the following:

• "Do you sometimes feel as if people are talking about you?"
• "Do you sometimes feel as if people are purposefully trying to injure or offend you?"
• "Have you ever felt as if you were receiving special messages through the television, radio, or some other source?"
• "Do you sometimes feel that you have special powers that other people do not have?"
• "Have you ever felt that something or someone outside of yourself was controlling your behavior, thoughts, or feelings against your will?"Examples of key probing questions for auditory hallucinations include:
• "Do you sometimes hear things that other people cannot hear?"
• "During these episodes, what exactly do you hear?"
• "If you heard voices, what were the voices saying?"
• "If you heard voices, did the voices tell you what to do, or criticize your thoughts or behaviors?"
• "How often do you have these experiences?"

Examples of key probing questions for AOD use disorders include:

• "Do you often drink or use other drugs more than you plan to?"
• "Have you made attempts to cut down or stop using alcohol and other drugs?"
• "How much time during the week do you spend obtaining, using, or recovering from the effects of alcohol and other drugs?"
• "Since you began using, have you stopped spending time with family and friends and begun spending more time using alcohol and other drugs or spending more time with people who do?"

It is important to recognize that direct interview questions will be of limited value for some patients in detecting substance use. Patients may underestimate, overestimate, or not recognize the severity or existence of their AOD use disorder.

There are several standardized instruments for AOD abuse screening and assessment. While valuable for assessing patients with AOD use disorders, these instruments have not been extensively tested among patients with concomitant psychotic and AOD use disorders. However, even brief instruments such as the CAGE questionnaire, the Michigan Alcohol Screening Test (MAST), and case manager rating scales will detect most AOD use disorders in this group.

Such instruments may be unreliable when used with patients who are acutely psychotic or whose residual impairments interfere with their capacity to respond to the interview questions. Since these tools involve self-report interviews, denial mechanisms may also reduce accuracy. Also, instruments that rely heavily on detecting signs of dependency syndromes (such as the Alcohol Dependency Scale) may fail to detect significant numbers of people with dual disorders. This is because even limited AOD use may be extremely problematic for patients with a psychotic disorder.

Especially for patients with psychotic symptoms, clinicians should inquire about the use, frequency, and quantity of all drugs of abuse, not merely alcohol. Also, clinicians can adapt the CAGE questionnaire (see Chapter 3) in such a way that the possible relation-ships between AOD use and psychotic symptoms can be elicited. For example, patients can be asked if they have cut down (or increased) their AOD use in relation to hearing "voices" or because of paranoia. They can be asked if they become more or less annoyed, angry, or irritable when using AODs. Clinicians can ask patients if they feel guilty about using AODs when taking medication, or if their guilt causes them to occasionally stop taking their medication.

Patients can be asked if AODs have been used to diminish the side effects of medications prescribed for psychiatric problems. Also, they should be asked if AOD use or withdrawal has ever been associated with a hospitalization or a suicide attempt. Patients should be asked if the frequency, quantity, and episode duration of their AOD use has changed and what consequences are associated with these changes.

Standardized assessment measures include the MAST, which has been demonstrated to have value for assessing this group. The Addiction Severity Index (ASI) is an instrument that guides the interviewer through a series of questions about drug use and consequences, as does the American Psychiatric Association's Structured Clinical Interview for DSM-III-R (SCID).

Alternatives to direct interview scales with demonstrated efficacy include case manager rating scales that are based on longitudinal observations of the patient, and aggregate multiple sources of information, including medical records, families, the criminal justice system, employers, landlords, and related sources. The patient's informed consent must be obtained before these contacts are made.

An important aspect of the assessment is the clinician's observations. The clinician should make careful note of the patient's overall behavior, appearance, hygiene, speech, and gait. Of particular interest are any acute changes in these behaviors, as well as the emergence of disorganized or bizarre thinking and behavior. A long-term therapeutic relationship with the patient increases the opportunity to make clinical observations that assist in making the differential diagnosis. Within this context, clinicians can better understand the relationships between the AOD use and the psychiatric symptoms.

As previously mentioned, data obtained from direct interviews and self-reports, as well as observational data, are limited. One important way of augmenting these approaches is to obtain information from collateral sources by directly interviewing family members and significant others about the psychiatric and AOD-related behavior of patients. The family interview can also be a useful means to obtain further information regarding family history of psychiatric and AOD use disorders.

Other collateral information can include available documentation such as medical and criminal justice records, as well as information gathered from other sources such as landlords, housing settings, social services, and employers. Case managers may be in a unique position to compile aggregate reports from these various sources, since they are able to follow these patients over an extended period of time in a variety of settings.

Laboratory tests for drug detection can be valuable both in documenting AOD use and in assessing AOD use in relation to psychotic symptoms. Objective urine and blood toxicology screens and alcohol Breathalyzer tests can be useful. Data from urine screens may be particularly useful for patients who deny regular use of AODs and who may benefit from objective feedback about the presence or absence of AOD use. Toxicology screens that document an absence of drug use can provide positive feedback for abstinent patients who are actively working to maintain sobriety.

Liver function tests have limited assessment value, particularly for patients ingesting large amounts of alcohol. However, the absence of abnormal liver findings should not be used as an indication of nonproblematic alcohol use.

While psychiatric, medical, or AOD-induced disorders may be more visible to the clinician than social problems, the latter can contribute significantly to the emergence and maintenance of these disorders. Indeed, the psychotic patient with dual disorders is more likely than not to have significant impairment in the social area. Thus, identifying the problem areas of a specific patient's social life becomes a core component of the service or treatment plan.

Actively helping patients to secure basic needs is a powerful way to engage them in the treatment process. Patients with dual disorders frequently face problems with living conditions, employment, homelessness, housing instability, loss of social support systems, and nutrition. The frustration and emotional turmoil that accompany problems in these areas can be intense. Indeed, many cases of treatment failure that are perceived as resistance to treatment and denial actually represent the failure of the treatment provider to recognize the impact of a patient's deteriorated social situation and to help the patient gain access to services.

In addition to social needs, clinicians should be aware of and sensitive to the impact of race, culture, ethnicity, nationality, gender issues, sexual orientation, and sexual history upon the lives of their patients.

A current or recent comprehensive medical evaluation is an essential aspect of the overall assessment. Nonmedical clinical personnel should become familiar with patients' medical histories and specifically inquire about the possible relationship between existing medical conditions and presenting symptoms.

Meeting the medical needs of patients with psychiatric and AOD use disorders is a critical aspect of treatment. For patients with psychotic disorders, attention to medical needs is even more important, since they generally have a high prevalence of medical problems, including chronic medical problems that are frequently untreated or undertreated.

During long-term treatment, it is important to evaluate the relationships between patients' medical problems and their psychotic and AOD use disorders. For example, medical problems may: 1) coexist with psychotic and AOD use disorders, 2) prompt or exacerbate psychotic and AOD use disorders, or 3) be the direct or indirect result of psychotic and AOD use disorders.

It is especially important for these patients to have easy access to treatment for medical conditions that are strongly associated with AOD use, such as tuberculosis, hepatitis, and HIV/AIDS. In addition, they should have easy access to treatment for basic medical needs, such as diabetes and hypertension, as well as cardiovascular, respiratory, and neurological disorders. Attention should be provided for the pregnant woman with regard to prenatal care and ongoing monitoring of pregnancy. The pregnant woman may be especially at risk for relapse when her regular antipsychotic medication regimen is contraindicated.

In addition to medical treatment, patients with dual disorders that involve psychosis need basic education about fundamental health care, hygiene, and AIDS prevention. A program that serves patients with dual disorders should include basic medical education components on site as a routine part of treatment, rather than referrals to another agency.

For patients who are prescribed medications, it is important to assess the types of medications, whether or not the medications are being taken, and the types of side effects they may cause. Patients should be asked specifically about the frequency, dosage, and duration of any prescription medication.

Medication noncompliance is the rule, not the exception, for people with dual disorders. Psychiatric medication noncompliance is particularly associated with dual disorders that involve psychosis, causing significant impact on presenting symptoms and level of function. Because of this common association between AOD use and noncompliance and the limitation of self-reports, it is useful to complement this assessment with an assessment of serum drug levels of psychiatric medications.

In addition to considering AOD use as a primary factor that affects the use of psychiatric medications, it is also important to consider the potential role of psychiatric medications in subsequent AOD use. For example, side effects such as akathisia (severe restlessness) or sedation may be caused by antipsychotic medications, and patients may take AODs in an attempt to medicate these unwanted side effects.

Frequently, psychoactive substances become replacements for adequate and nutritious food. Nutritional impairment is associated with impaired cognition. A lack of regular meals and poor nutrition are common occurrences among patients with dual disorders; thus, access to regular meals should be assessed.

Also, acute dental problems as well as ongoing dental care should be assessed. Because this group frequently experiences financial difficulties, access to dental care is often limited or nonexistent. Attention should be given to the social and emotional consequences of poor dental health, such as poor self-esteem and diminished social interaction.

The most important initial step in treatment is to identify high-risk conditions that require immediate treatment, while recognizing that there will likely be important issues that require long-term management.

Within the area of acute management, it is useful to differentiate between acute management of crises and the resolution of subacute problems that may be severe but not life threatening.

The initial critical consideration for high-risk conditions is to determine if patients require emergency medical treatment, psychiatric treatment, or both. The critical decision is whether patients require hospitalization, and if so, what type of treatment is required (for example, primary health care, detoxifi-cation, or psychiatric care). This aspect of treatment necessarily involves medical assessment and intervention.

With regard to biological or medical issues, the priority is addressing and stabilizing the acute crisis in a hospital-based setting. Once the acute crisis has been stabilized, mental health and AOD use consultation may be necessary to address the concomitant psychiatric and AOD disorders.

With regard to high-risk psychological conditions (that is, danger to self or others and other violent and impulsive behavior), the initial focus is on stabilizing the acute psychological crisisÒproviding that acute medical causes have been ruled out. Stabilization may require acute involuntary psychiatric hospitalization. Thus, coordination with emergency mental health services and the local police department is necessary to ensure the immediate safety of the patient and others.

With regard to high-risk social conditions (homelessness, housing instability, victimization, and unmet basic needs), the priority is on implementing aggressive social crisis intervention. Meeting patients' basic needs is critical in the management of the treatment of dual disorders that include psychosis. The high-risk social conditions may be related to the medical or psychiatric crisis, and therefore will require followup upon hospital discharge.

Regardless of the priority of crisis intervention, the overall biopsychosocial needs of patients must be addressed in a holistic manner, considering both the psychosis and the AOD use disorder. The approach must be integrated and comprehensive despite the higher visibility of one of the disorders.

Following the resolution of the acute crisis, subacute conditions must be addressed before long-term management can occur. (Subacute conditions can also occur as a precursor to acute relapse of psychiatric symptomatology or AOD use.) Examples of specific subacute management issues include resuming or adjusting psychotropic medication, patients' comfort with the medication, medication compliance, addressing acute psychiatric symptoms, establishing early AOD use treatment intervention, and establishing or sustaining patients' connection with support systems and services for obtaining housing and meeting basic needs.

The subacute phase allows for an opportunity to reassess the diagnosis and overall treatment needs. The ultimate goal should be to establish a long-term treatment plan, to avert imminent decompensation or relapse, and to address long-term needs.

The overall goal of long-term management should involve: 1) providing coordinated and integrated services for both the psychiatric and AOD use disorders, and 2) doing so with a long-term focus that addresses biopsychosocial issues.

Patients with severe or persistent psychiatric and AOD use disorders, such as Thomas, require dually focused, integrated treatment. Patients like Martha, who have mild or brief symptoms of mental illness, may benefit from parallel treatment or self-help. Patients with AOD-induced psychiatric symptoms similar to Laura's should receive long-term management and treatment by AOD abuse treatment providers. Irrespective of the treatment setting, the goal is to help patients with dual disorders gain control over their psychiatric and AOD use disorders.

Gaining such control is a long-term process. For this group, the initial expectation during the engagement period should not be immediate compliance with psychiatric treatment or immediate abstinence. Indeed, mandating these treatment prerequisites may interfere with access to services or lead to the patient's rejection of the treatment services. Abstinence from AOD use is the long-term goal for patients with dual disorders that involve psychosis, but should not be a prerequisite for offering or continuing treatment services.

The first step in the long-term treatment of patients with dual disorders that involve psychosis is to engage them in the treatment process. The basis of therapeutic engagement is building a relationship with patients. Engagement is a long-term process, not a single event that occurs only during the initial stages of treatment. The engagement process may need to be revisited throughout the course of treating these two unremitting disorders.

Frequently, patients with dual disorders do not acknowledge or appreciate that AOD use or a psychiatric disorder is a problem in their lives. Hence, establishing a relationship with these patients may first require knowing what they want and need. They may not want AOD treatment or psychiatric services. Rather, they may best be engaged by offering them assistance to meet their basic needs such as housing or entitlements or by providing basic medical and legal services.

A variety of approaches can be used to facilitate the engagement process. These include assertive outreach by case managers and clinicians, offering to facilitate the acquisition of basic services and entitlements and help with legal services. Similarly, engagement may be facilitated through involvement with alternative social and recreational activities, programs, clubs, and drop-in centers.

Engagement techniques can include the therapist's involvement with the family and other significant parties. Indeed, at times, clinicians may be able to maintain contact with patients only through the family.

Patients often want help finding and keeping a job. Thus, engagement includes vocational rehabilitation.

For patients who have particularly severe psychiatric or AOD use disorders and do not respond to these initial attempts at engagement in the treatment process, the use of therapeutic coercive approaches may be necessary. Patients with severe dual disorders may have gross cognitive impairment due to AOD use and may be severely disorganized due to psychiatric illness. They may be impulsive, exhibit extremely poor judgment, or be chronically dangerous to themselves or others.

Without therapeutic coercive interventions, some of these patients may be at substantial risk of catastrophic outcomes, including death, injury, violent behavior, or long-term incarceration. Examples of therapeutic coercive approaches include the appointment of a representative payee, guardian, or conservator and the use of parole or probation. Legal advocacy by a case manager for court-mandated treatment services may be essential for engaging and maintaining treatment services. Other mechanisms include commitment to outpatient treatment services, conditional discharge, and commitment to appropriate inpatient dual disorder treatment.

Therapeutic coercive efforts should be temporary and reserved for patients who have failed with other interventions. The long-term goal for these patients is to regain control over their lives. As mentioned above, service providers have traditionally expected patients to be motivated before initiating treatment. They have often misinterpreted the lack of engagement as denial or resistance to treatment.

It is essential for treatment professionals to understand that the provider is responsible for motivating or providing incentives for the patient to engage and remain in treatment.

Service providers in traditional treatment programs have often maintained that patients with dual disorders should be treated sequentially, that is, by treating the AOD use disorder before treating the psychiatric disorder, or vice versa. Rather, there should be an ongoing dual focus on both disorders, especially for patients with psychosis or AOD use disorders.

Particularly for the severely disorganized patient or for the patient with persistently disabling conditions, integrated treatment is essential. Ideally, the services should be integrated within the same agency and program.

When mental health and addiction treatment services are not integrated, fragmentation of services and discontinuous service are significant risks. In situations where services cannot be integrated, it is crucial for one provider to accept full responsibility for the patient and to aggressively coordinate service with other programs and services. For treatment to be effective, and to ensure continuity of care, a long-term relationship and treatment approach should be developed.

For patients with milder psychiatric symptoms, parallel treatment approaches such as concurrent psychiatric and AOD treatment may be helpful, although such approaches have the disadvantage of placing the burden of integrating different treatment options on patients. This burden should be minimized by a case manager or clinician who can provide appropriate clinical liaison between different agencies.

For patients with dual disorders involving psychosis, a long-term approach is imperative. Research has shown that individuals become abstinent and gain control over psychiatric symptoms through a process that frequently takes years, not days or months. Front-loaded, intensive, expensive, and highly stimulating short-term treatment modalities are likely to fail with this group of patients.

Both psychotic and AOD use disorders tend to be chronic disorders with multiple relapses and remissions, supporting the need for long-term treatment. Also, an accurate diagnosis and an assessment of the role of AODs in the patient's psychosis necessitate a multiple-contact, longitudinal assessment and treatment perspective.

Especially for programs that treat patients with psychotic and AOD use disorders, it is essential that the program philosophy be based on a multidisciplinary team approach. Ideally, team members should be cross-trained, and there should be representatives from the medical, mental health, and addiction systems. Staff members should learn to use gentle or indirect confrontation techniques with these patients.

Team members should endorse an assertive case management approach, wherein the case manager is not limited to the treatment site, but is expected to provide services to patients in their own environments. The case manager must not attempt to solely broker treatment services or exclusively provide office-based treatment. A supportive and psychotherapeutic approach to individual, group, and family work should be employed.

For these patients, flexible hours are necessary. Because crises frequently occur during evening and weekend hours, services should be provided during these hours. In addition, alternative social activities and peer group activities often take place in the evening and on weekends.

Also, individual and group programs for patients with dual disorders that involve psychosis should be based on a behavioral and psychoeducational perspective, not a psychodynamic approach. Educational information should be frequently repeated and presented in concrete terms using a multimedia format. Programs should be modified to include frequent breaks and shorter sessions than normal.

Special care should be taken with regard to patient education and group discussion about Higher Power issues. Staff members should be trained to teach patients and lead group discussions about spirituality and the concept of a Higher Power. Staff members should understand the difference between spirituality and religion, and especially the differences between spirituality, religion, and delusional systems that have a religious or spiritual content.

It is essential that the treatment plan for each patient be personalized, and based on the specific needs and stated goals of the patient, rather than on the clinician's goals. The patient should participate in the ongoing review and evaluation of the treatment plan.

Even intensive, carefully designed AOD abuse treatment is likely to fail if the extensive psychosocial problems associated with dual disorders are not concurrently addressed. Common psychosocial concerns of this group include housing, finances and entitlements, legal services, job assistance, and access to adequate food, clothing, and medication.

A particularly common complication of dual disorder patients with psychosis is housing instability and homelessness. Among the possible housing services that may be particularly useful are shelters, supervised housing settings, congregated living settings, treatment milieu settings, and therapeutic communities. Ideally, residential options and placements should be long term, with the goal of promoting independent, stable, and safe housing.

Despite the long-term goal of sobriety, the housing needs of patients with chronic psychosis and AOD use disorders may be met temporarily by housing that is not explicitly drug free. Shelters or other forms of temporary housing that are not explicitly drug free but provide basic safety from weather and violence are better than no housing at all.

Various housing settings are necessary, including housing for current AOD-using individuals ("wet" or "damp" housing setting) and settings for individuals who are abstinent. Although there is a need for this broad range of housing, many communities do not currently have it. Within this range of agency-supported housing, there should be explicit policies regarding AOD use, understood by both the patient and the clinician.

It is also critical for treatment programs to have easy access to housing for patients with special needs, such as women and children, pregnant women, and battered women. Specific housing should be developed for patients with specialized, ongoing medical and psychological needs associated with complications of serious medical conditions such as AIDS.

Vocational services are also essential for the long-term stabilization and recovery of the dual disorder patient. Both AOD and mental health services have traditionally referred clients to generic vocational rehabilitation services. These services must be integrated and modified for the specialized needs of the individual with psychosis and AOD use disorders. Temporary hire placements and job coaching options are important elements to incorporate into rehabilitation services for this group.

An essential part of treatment for patients with dual disorders is the development of alternative peer group settings that do not include drug use. Developing these non-AOD-using social networks can be enhanced by programs that provide social club activities, recreational activities, and drop-in centers on site, as well as linkages to other community-based social programs. At the same time, patients should be encouraged to establish and maintain relationships, including family relationships, that are supportive of treatment goals.

Treatment of the dual disorder patient can be substantially supported and enhanced by direct involvement of the patient's family. Services can include family psychoeducational groups that specifically focus on education about AOD use disorders and psychosis. This also includes multifamily treatment groups that may include the individual with the dual disorder.

Families may also be helpful in identifying early signs of psychiatric or AOD use relapse symptoms. They can work with the treatment team in initiating acute relapse prevention and intervention. Confidentiality issues need to be addressed at the beginning of treatment, with the goal of identifying a significant support person who has the patient's permission to be involved in the long-term treatment process.

An essential component of relapse prevention and relapse management is close monitoring of patients for signs of AOD relapse and a return of psychotic symptoms. Relapse prevention also includes closely monitoring the development of patients' AOD refusal skills and their recognition of early signs of psychiatric problems and AOD use. The goals of relapse prevention are: 1) identification of patients' relapse signs, 2) identification of the causes of relapse, and 3) development of specific intervention strategies to interrupt the relapse process.

Close monitoring involves the long-term observation of patients for early signs of impending psychiatric relapse. Such signs may include the emergence of paranoid symptoms and symptoms related to AOD use such as hostile or disorganized behavior. For example, a sign of paranoid symptoms may be the patient's sudden and constant use of sunglasses. Additional important clues may involve changes in daily routine, changes in social setting, loss of daily structure, irritation with friends, and rejection of help. Family members who reside with the dual disorder patient are often the first to detect early signs of psychotic or AOD use relapse.

Additional signs of possible psychotic or AOD relapse include eviction from housing, job loss, or involvement with the criminal justice system. It is important that the clinician understand that routine daily stressors may have an intense impact on the dually diagnosed patient and may prompt relapse.

Objective laboratory tests may also be particularly useful in detecting early risk of AOD relapse. This includes the use of random urine toxicology screens, the alcohol Breathalyzer test, and blood tests to detect street drugs. As medication noncompliance is strongly associated with both AOD use and psychotic relapse, blood medication levels (including antipsychotic and lithium levels) may be particularly useful. Finally, intramuscular forms of antipsychotic medications may be particularly useful for verifying and assuring long-term compliance with antipsychotic medications.

In addition to close monitoring by health care professionals, family members, and significant others, an important component of relapse prevention is assisting the dual disorder patient to develop skills to anticipate the early warning signs of psychiatric and AOD use disorders. These skills can be acquired through direct individual psychoeducation and participation in role play exercises and psychoeducation groups. These patients should be trained to use AOD refusal skills and to recognize situations that place them at risk for AOD use.

Similarly, these patients may benefit significantly from behavioral therapy; development of relaxation, meditation, and biofeedback skills; exercise; use of visualization techniques; and use of relapse prevention workbooks. Pharmacologic strategies may include the use of disulfiram or naltrexone for certain patients.

Group process is a core element of AOD abuse and mental health treatment. However, for patients with psychosis, group treatment should be modified and provided in coordination with a comprehensive service plan. The different types of groups specifically designed for the dual disorder patient include persuasion groups, active treatment groups, dual disorder-oriented 12-step groups (Double Trouble groups), pre-12-step groups, and groups that focus on medication and anger management.

Groups that are specifically designed for dual disorder patients are essential during the early phases of treatment. Patients who have accepted the goal of abstinence, have maintained psychiatric stability, and have essential social skills may benefit from carefully selected traditional 12-step programs that are sensitive to the needs of the severely mentally ill. However, during the early phases of treatment, an unfacilitated referral to traditional 12-step programs will likely result in treatment failure. (See the discussion on the use of the 12-step programs in Chapter 6.) A wide variety of group settings may be useful for the person with a dual disorder. However, the core approach should include psychoeducational, supportive, behaviorally oriented, and skill-building activities.

With patients who have dual disorders that involve psychosis, a common provider mistake that often leads to psychiatric or AOD use relapse involves a lack of attention to medication issues. Most important, treatment programs must provide aggressive treatment of medication side effects. Ignoring the side effects of prescribed medication often results in patients using AODs to diminish the unwanted medication side effects.

Equally important, patients should be educated and thoroughly informed about: 1) the specific medication being prescribed, 2) the expected results, 3) the medication's time course, 4) possible medication side effects, and 5) the expected results of combined medication and AOD use. Whenever possible, family members and significant others should be educated about the medication.

Medication should not simply be prescribed or provided to the psychotic patient with dual disorders. Rather, it is critical to discuss with patients 1) their understanding of the purpose for the medication, 2) their beliefs about the meaning of medication, and 3) their understanding of the meaning of compliance. It is important to ask patients what they expect from the medication and what they have been told about the medication. Overall, it is important to understand the use of medication from the patient's perspective. Indeed, informed consent relative to a patient's use of medication requires that the patient have a thorough understanding of the medication as described above.

It is also important to help patients prepare for peer reaction to the use of medication when they participate in certain 12-step programs. Patients should be taught to educate other people who may have biases against prescription medications or who may be misinformed about antipsychotic medications.

Patients receiving medication should participate in professionally led medication education groups and medication-specific peer support groups. These groups will help patients deal with the emotional and social aspects of medication, promote medication compliance, and help clinicians and patients identify and address early noncompliance and side-effect problems.

Overall, there must be a specific and aggressive treatment strategy that helps make medication use simple and comfortable. The scheduling and administration of medication should be simple and convenient for patients. The ideal schedule for oral medications is once per day. The use of injectable medications may be the most comfortable and effective option for some patients with dual disorders.

Anything that helps patients feel more comfortable about taking medication should be considered. In addition, an important treatment goal is a medication regimen that is self-monitoring.

When patients experience difficulty acquiring medication, the treatment program should directly help patients acquire them, not make referrals and recommendations.

Traditional training in mental health and AOD abuse treatment, and in medicine in general, has been inadequate relative to the unique needs of the dual disorder patient. Thus, program staff require ongoing education about current understanding and treatment of dual disorders. It is imperative that the service principles of each discipline be presented and modified for application to people with dual disorders. Training also must be integrated, not sequential or parallel.

Perhaps the most important goal of clinical staff development and training is the cross-training of addiction and mental health personnel. Addiction specialists need training in psychiatric and mental health issues, while mental health and psychiatric specialists need training in AOD and addiction issues. In addition to cross-training, both addiction and mental health clinical staff require clinical and theoretical training in dual disorders.

Clinical staff training content must include information about the assessment and treatment of high-risk and subacute problems and about long-term treatment issues. There must be a focus on the interaction between AOD use and psychiatric symptoms. In addition, attention must be given to high-risk behaviors such as violence to self or others, suicide, impulsive behavior, and high-risk sexual behavior.

Clinical staff training must also address less obvious clinical issues such as cultural competency and sensitivity to the roles of culture, ethnicity, nationality, religion, and spirituality.

While 1- or 2-day workshops may be useful for disseminating clinical information, ongoing and routine education is critical. To emphasize the multidisciplinary team approach, staff education should be done in a group setting with interaction among group participants and trainers.

The need for clinical supervision among clinical staff is crucial. Supervision must be an ongoing, routine process, not driven by clinical crises. Nonetheless, because treatment of dual disorders involves frequent crises, the clinical supervisor must be readily available to team members and able to provide rapid coaching and support.

An important aspect of clinical supervision and clinical staff development is education in the theoretical basis of treatment. Irrespective of disciplines, all clinical staff must thoroughly understand and support the philosophical basis, values, and goals of the treatment program in which they work. Further, an important task of the clinical supervisor is to integrate the formal theory and principles within the specific treatment setting.

Clinical staff education and development must include the formation of procedures and supports to prevent staff burnout and demoralization. Components of staff burnout prevention include mechanisms for multidisciplinary group support, a focus on long-term rather than short-term gains for patients, anticipation and expectation of relapse as part of psychotic and AOD use disorders, and an understanding of relapse as a treatment opportunity rather than a treatment failure.

Program administrators, whether they are in contact with patients or not, require clinical education in dual disorder issues to provide an appropriate environment for the treatment of patients with dual disorders and to better understand the needs of staff and patients. Thus, program administrators require education in the latest conceptual and technological developments in the fields of psychiatry and AOD treatment as well as in dual disorders.

It is important for program administrators to regularly review, articulate, and discuss the program's philosophy, goals, and objectives with all program staff. Enhanced and open communication between administration and staff in both individual and group settings is also critical. For example, administrators should regularly communicate with staff regarding administrative constraints such as financial limitations, legal mandates, and political influences.

Administrators should thoroughly understand the appropriate role of clinical supervision: that this supervision is designed for skill enhancement and staff support. Clinical supervision skills are critical for providing effective services to high-risk populations such as patients with psychotic and AOD use disorders.

There should be open discussion of administrative styles, since these significantly affect staff morale and performance. Similarly, administrators should be aware of the influence of their personal characteristics upon staff and patients. For example, administrators should become aware of the influence that their culture, ethnicity, gender, sexual orientation, and background has on others.