Chapter 8 — Psychotic Disorders Dual-Focus Perspective
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
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. .
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. .
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
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
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
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:
Examples of key probing questions for AOD use disorders include:
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-ter