There are several societal, diagnostic, treatment, and psychodynamic features that are common both to substance dependence and personality disorders. When working with the dually disordered, these factors interact with and mutually reinforce each other.

1) Diagnosis

There is a lack of clarity in the diagnosis of both disorders. There are no definitive answers; no definitive theory bases. Some treatment approaches are mutually exclusive and cause dissension.

For personality disorders, there are advocates for both categorical and dimensional models of classification. There is considerable discussion regarding how many personality disorders should be listed in the DSM. In addiction, there are psychological, medical, and social models of definition, classification, and treatment.

Members working on a treatment team may not adhere to the same approach and may have to struggle with disagreement and opposition from each other.

2) Continuum

Both substance dependence and personality disorders can be conceptualized as existing on a behavioral continuum from normal to pathological. Where individuals fall on this continuum is a matter of clinical judgement, and often, a matter of disagreement between the clients and the service providers.

3) "Poly" Disorders

Substance abuse/dependence and personality disorders frequently exist in multiple form. Individuals may well evidence polysubstance abuse and, if there were such a word, "polypersonality" disorders as well. Research has demonstrated that individuals having more than one personality disorder is more the norm than the exception.

4) Denial

Service providers are trying to diagnose what clients with addiction or personality disorder are denying, minimizing, or trying to hide. Few addicted individuals come into an intake assessment prepared to make a full disclosure of their patterns of substance use. Similarly, few personality disordered individuals acknowledge their maladaptive and provocative behaviors. Both disorders are misrepresented by client self-report and involve the clients' insistence that the real problem lies elsewhere, usually in how they are being treated by others. Diagnoses must come from observation, interpretation, extrapolation, information from objective (tests) and non-client (family) sources.

5) Camelot

Clients are using, in both, defenses to sustain a maladaptive pattern of preferred behavior. In treatment, they are being asked to accept responsibility for their lives and their future, but they dread the loss of their illusions and fear the treatment providers' reality. They want to believe they have found a way to escape from the pain of life on its own terms. Both disorders can, in effect, be an attempt to ":cheat": on life, i.e., an attempt to live as an adult without accepting responsibility for self or the consequences of behavior.

6) Immaturity

Immaturity, in the form of immature defenses, may well play a causative role in both disorders. It is most certainly a result of long-term substance dependence and disordered behavior. Immaturity is a factor in the recovery from both disorders. Treatment is often a process of growing up; many personality disordered and addicted individuals are not sure they can do that and they are not totally convinced it is such a good idea in the first place.

7) Accepting Corrective Feedback

Both personality disordered individuals and substance dependent individuals are severely limited in their ability to receive, accept, or benefit from corrective feedback. The impact over time begins to be more severe than simple immaturity. Increasing dislocation from reality-testing leads to ever greater inappropriateness and eccentricity. Over time, the consequences of behaving as though ":reality does not apply": grow ever more severe in all areas of life: marriage, work, the legal system, medical issues, and social interaction.

8) Expense of Treatment

Society wants the service provider to treat these people as quickly and as inexpensively as possible. However, David Adler (1990) referred to the personality disordered treatment population as ":chronic, non-psychotic clients;": substance abuse/dependence is also a chronic disorder. Both involve the ongoing risk of relapse. Relapse in one increases the likelihood of relapse in the other.

All of these factors affect both disorders. The impact on the dually diagnosed is incrementally greater. Both disorders exacerbate, augment, and reduce the potential of a positive treatment outcome of the other.

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General Definition

The concept of personality disorder has been around since the time of Hippocrates. Aristotle's pupil, Theophrastus, delineated a series of characters with a core element of personality disturbance that bear a substantial resemblance to current personality disorders. For example, he described the ":vain": man who has a ":paltry desire for distinction;": the ":boaster": who pretends to have advantages not personally possessed; the ":arrogant": man who has contempt for everyone except himself; the "e;grumbler"e; who complains too much about his lot; the ":friend of rabble": who has a taste for vice; and the "e;distrustful"e; man who suspects all men of dishonesty (Tyrer and Ferguson, Tyrer, editor, 1988, pp. 1-2).

Currently, personality disorders are diagnosed when personality traits are inflexible, maladaptive, and cause impairment in functioning across a wide range of personal and social situations. Individuals with a personality disorder are locked into long standing cognitive, affective, interpersonal, and impulse control patterns that lead to repeated antagonistic, disruptive and self-defeating experiences (DSM-IV?, 1994, p. 630). Personality disordered individuals have trouble responding flexibly and adaptively to the changes and demands that are an inevitable part of everyday life (Frances, 1995, p. 357); instead, they utilize maladaptive behaviors that have helped them to survive in difficult past situations called "e;survivor behaviors"e; (TIP #9, 1994, p. 55).

Benjamin (1993, p. 4) states that nearly one in ten adults is personality disordered; over half of the adults in mental health treatment are personality disordered. Nace (1990, p. 187) contends that the prevalence of personality disorders is at least 50% in substance abusing populations. Tyrer, Casey, and Ferguson (1988, pp. 95-98) cite studies indicating 69% of individuals with alcohol dependence and abuse also have a personality disorder and 44.9% of individuals with schizophrenia also have a personality disorder. Dowson and Grounds (1995, p. 133) note a study of alcoholic outpatients in which it was determined that 64% had a personality disorder. Of these, 44% had a paranoid personality disorder, 20% had an antisocial personality disorder, 20% had an avoidant personality disorder, 18% had a passive-aggressive personality disorder, and 16% had a borderline personality disorder (presumably some subjects in the study met the diagnostic criteria for more than one personality disorder -- hence a total that is more than 100%).

Dowson and Grounds (1995, pp. 4-32) state that personality disorders are often the origins of homelessness, alcoholism, drug abuse, neglect of children, criminality, HIV transmission, accidents, and driving offenses. Personality disorders are also associated with a high rate of consultations for physical symptoms that have no clear diagnosis; up to 34% of patients in primary medical care settings have been identified as having personality disorders. One of the most frequent reasons that primary care physicians refer patients for psychiatric care is the presence of personality disorder -- yet in many instances the referral is made without personality status being identified (Tyrer & Seivewright, 1988, p. 130).

DSM-IV? (1994, p. 633) General Criteria for Personality Disorder

• An enduring pattern that deviates markedly from the person's culture in 2 or more of the following:

  Cognition (perception & interpretation);

  Affect (range, intensity, lability, and appropriateness);

  Interpersonal functioning;

  Impulse control.

• The enduring pattern is inflexible and pervasive.

• The enduring pattern leads to significant distress or impairment in social, occupational, or other areas of functioning.

• Onset is in adolescence or early adulthood.

• The pattern is not better accounted for as a consequence of another mental disorder, substance abuse, or another medical condition.

The ICD-10 (1994, pp. 221-222) states that personality disorders involve behavior patterns that are the expression of individuals' characteristic lifestyle and mode of relating to themselves and others. These behavioral patterns must deviate markedly from the culturally expected in at least two areas including:

• cognition;
  
• affect;
  
• impulse control/need gratification; and,
  
• interpersonal relationships.

Dowson & Grounds (1995, pp. 17-20) note that the DSM-IV? categorical approach assumes that some members of each personality disorder are "e;better"e; examples of that category than others. A group of individuals who receive a diagnosis of a specific personality disorder are heterogeneous in respect to that disorder as there are many different combinations of the minimum number of positive criteria required.

Beck, et.al. (1993, pp. 269-270) notes that personality-disordered individuals typically demonstrate the following common features:

• The chronic symptoms are ego-syntonic, i.e., these individuals do not particularly see anything wrong with their personality. In treatment, they usually want relief from anxiety or depression. They do not seek help for character-related issues.
  
• Personality-disordered individuals usually engage in behaviors and have attitudes that are noxious to others. They often cause considerable hardship for those with whom they interact.
  
• These individuals are extremely resistant to change; they are disinclined to alter their maladaptive behaviors or attitudes.
  
• Personality-disordered individuals have difficulty imagining being any other way. Their problems are synonymous with their identities. To change may feel like virtual personal annihilation.

The general personality disorder characteristics observed in a clinical setting include:

• An inclination to be demanding and non-compliant (actively or passively). For some of the personality disorders, this is apparent early in treatment; for others the non-compliance is evident only after early success in the therapeutic process (e.g. an individual with a dependent personality disorder, for whom continuing positive change would result in termination from therapy, who is unable to initiate or sustain self-responsible behavior).
• A tendency to engage in over or under valuation of self as well as over or under valuation of others. Individuals with personality disorders often alternate between extremes (e.g. idealizing and then villainizing a spouse or therapist, or feeling superior to and then inferior to or unworthy of others).
  
• A propensity toward manipulativeness with significant corresponding interpersonal dishonesty (e.g. suicidality in the service of binding a caretaker and preventing abandonment).
  
• Difficulties in developing non-pathological attachments (e.g. seeking in a significant other the "e;good parent,"e; a shield against a hostile world, a caretaker who will make functioning as an adult unnecessary, a "e;you and me against the world"e; alliance).
  
• A failure to accept and/or process corrective environmental feedback with an inclination to frame reality around self and self-needs without considering the reality of others. This behavior can leave others both bewildered and enraged as the personality disordered individual fails to receive, understand, or respond appropriately to feedback.
  
• A lack of awareness of impact on others with a corresponding failure to assume responsibility for self. When confronted, personality disordered individuals will deny, minimize, distort, or counterattack in the face of criticism or demands for appropriate behavior.
  
• A tendency toward self-defeating, self-damaging, or self-destructive behavior (e.g. self-mutilation, grandiose arrogance, provocative aggressiveness, failure to assert self, willingness to tolerate abuse, withdrawal and isolation).
  
• Affective dysregulation, e.g., irritability, instability, effusiveness, or constriction.

Medication for Individuals with Personality Disorders

Most of the literature suggest that drug therapy should be directed at specific symptoms, regardless of the type of personality disorder. This would include:

• Antipsychotics, usually in low doses for brief periods of time, for paranoia, impulsivity, cognitive disorders, and transient psychosis.
  
• Antidepressants for panic attacks, phobias, ADHD, compulsivity, and depression.
  
• Mood stabilizers for dyscontrol, rage, violence, affective lability, and impulsivity.
  
• Anxiolytics for panic disorders, social phobia, and agoraphobia.

The critical therapeutic techniques when medicating clients with personality disorders are:

• Emphasizing that drugs are not a panacea or magic answer;
  
• Addressing unrealistic expectations for therapy and/or medication;
  
• Always providing concurrent non-pharmacological treatment;
  
• Avoiding polypharmacy (multiple concurrent drugs);
  
• Utilizing informed consent (Janicak, 1993, p. 517).

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General Definition

The power and appeal of drugs has been known to psychiatry for a very long time. Freud (Khantzian, et.al., 1990, cover page) described intoxicating substances as making it possible to keep misery at a distance. Drugs not only yield immediate pleasure, they provide a greatly desired degree of independence from the external world. With the help of drugs, anyone can withdraw from the pressures of reality and find refuge in a world of one's own that is easier on one's sensibilities than the real world. The appeal of such power should be very apparent for individuals with personality disorders.

According to the DSM-IV? (1994, p. 181), substance dependence is a maladaptive pattern of substance use. There must be 3 (or more) of the following occurring at any time in the same 12-month period:

• Tolerance;
  
• Withdrawal;
  
• Use of larger amounts or over a longer period than was intended;
  
• Persistent desire (craving);
  
• Preoccupation;
  
• Important activities are given up;
  
• Use continues despite persistent problems (physical or psychological) that are caused or exacerbated by the substance).

1) The substance dependence is specified as being with (evidence of tolerance or withdrawal) or without physiological dependence.

2) The substance dependence is specified according to course, e.g. remission status, use of agonist therapy, or in a controlled environment.

According to the ICD-10 Classification of Mental and Behavioural Disorders (1994, pp. 79-81), diagnosis of the Dependence Syndrome involves three or more of the following, occurring together for at least one month, or repeatedly within a 12-month period:

• Compulsion;
  
• Impaired capacity to control substance use;
  
• Physiological withdrawal;
  
• Tolerance;
  
• Preoccupation;
  
• Continued use despite harmful consequences.

1) May be specified by current status of abstinence, client placement in a controlled environment, use of replacement drug, e.g. methadone, blocking drugs, e.g. naltrexone, or currently active.

2) Further specifiers, if desired, are continuous or episodic use.

In Alcoholism and Other Drug Problems, Royce and Scratchley (1996, p. 130) state that addiction is a state involving the whole person; it is a way of living. Compulsivity, not physical adaptation, is central. For example, pathological gambling shows patterns of brain activity similar to drinking and drugging. The parallels in all addictive behavior have become more evident as research reveals a common pleasure center in the brain.

Addiction may also be conceived of as a biopsychosocial disorder:

• Biologically, addiction resides in the neurotransmitters in the brain. Essentially, mood change can be accomplished through the ingestion of a substance or engaging in an activity that successfully alters the chemistry of the brain in the desired direction. The drug or activity must be powerful, rapid in impact, and either reduce pain or enhance pleasure.

• Psychologically, addiction is the management of the feelings associated with a problem instead of a response aimed at the actual problem; the addict is trying to be happy by manipulating feeling states rather than by coping with reality (Hoskins, 1989, p. 37). The preferred drug or activity will fit with an individual's existing patterns for managing psychological threat (Milkman & Sunderwirth, 1987, p. xiv).

• Socially, patterns of addiction occur and may be sustained in interactions with other individuals, groups, and societal institutions. The addict attempts to create a social structure which supports the addictive patterns while fighting off elements which interfere with them.

A note regarding dual diagnosis: the overlap of alcoholism and drug addiction is not usually considered dual diagnosis. However, clinicians do need to appreciate the extensive overlap between abuse of alcohol and abuse of other drugs. Failure to diagnose all substance abuse disorders may lead to:

• A complicated, dangerous, or unsuccessful detoxification;

• Development of a new addiction after an initial addiction is arrested. Clients usually hope that at least one drug will be okay--usually a drug they do not yet have a problem with; they hope to ignore the treatment principle that they must eliminate the use of all intoxicating substances (Nace, Brown, ed., 1995, pp. 167-168).

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According to Edgar P. Nace (1990, p. 186), the most severe levels of substance abuse are associated with character pathology rather than serious mental illness. Individuals with a personality disorder:

• are more vulnerable to substance abuse than non-personality disordered individuals;
  
• experience greater benefit from the pharmacologically induced effects of drug use than those experienced by a better integrated personality;
  
• are more likely to engage in substance abuse at an earlier age and polydrug use with greater frequency than individuals without a personality disorder.

Abstinence in the personality disordered substance abuser depends upon the development of frustration tolerance, patience, impulse control, and an ability to regulate affect.

In most cases, the personality disorder precedes the substance abuse. However, substance abuse may produce a syndrome diagnostically compatible with personality disorders. Substances can produce a combination of toxic and organic effects on the brain; they can also reinforce regressive behavior. This combination may result in a personality disorder that is secondary to alcoholism and drug dependence. This addicted personality (the effect of chronic use of drugs or alcohol on personality functioning) is marked by impulsivity, decreased frustration tolerance, self-centeredness (stubbornness, defiance, lack of empathy), grandiosity (overvaluation or undervaluation of self), passivity, and affect intolerance (Nace, Brown, ed., 1995, pp. 175-176).

Beck, et.al. (1993, p. 270) notes that when a personality disorder contributes to drug use the pattern becomes more compulsive and rigid. Once the alcohol or drug use begins, personality-disordered individuals are more likely to continue using until they go into a full-blown addiction. These individuals are also more vulnerable to relapse and have more difficulty working cooperatively and collaboratively with service providers.

Henry Jay Richards (1993, p. 236) views persistent addiction as related to failures in self-regulation. The most important mediator of self-regulation is the personality. If there is personality pathology related to cognitive style, affective tolerance, activity, interpersonal style and relationships, there is vulnerability to addiction.

It was noted in the Treatment Improvement Protocol #9, Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse (1994, p. 55), that people with a personality disorder use drugs or alcohol for purposes related to the personality disorder, e.g. to enhance self-esteem, manage symptoms of the personality disorder, manage negative affect, and amplify feelings of individuality.

Ruegg and Frances in "e;New Research in Personality Disorders"e; (1995, p. 7) suggest that substance abuse by individuals with a personality disorder results in the presence of greater personality disturbance and poor outcome of therapy (either mental health or addiction counseling); long term abstinence is associated with remission of the personality pathology.

No single pattern of substance use or abuse can be identified for any one of the personality disorders. No personality disorder evidences uniform choice of one drug or class of drugs over others. There may be patterns of use that can be noted, but there will be many exceptions. The drug or drugs of choice depend upon many factors beyond the presence of a specific personality disorder.

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Studies have shown that treatment of underlying psychiatric disorders does not alter the use of alcohol and drugs "e;which persists despite the worsening of psychiatric symptoms induced by alcohol and drugs"e; (Miller, 1995, p. 65).

The presence of personality disorders substantially increases the individual's risk of failure to achieve abstinence and to relapse.

Individuals with both substance abuse or dependence and a personality disorder will also be vulnerable to other Axis I disorders. Diagnosis is a dilemma as intoxication, withdrawal, and post acute withdrawal all confound an accurate diagnosis of anxiety or affective disorders. Personality disorder dynamics impact Axis I disorders in many ways, e.g. an individual may experience intense sensitivity to or over-report anxiety symptoms as a result of or in the service of personality characteristics. Nace (Brown, ed., 1995, p. 173) suggests the following as a useful guide for initiating treatment for co-occurring Axis I disorders:

• For anxiety, affective, and psychotic disorders delay specific treatment if the symptoms are transient and diminishing and if functioning is not compromised.
  
• Treatment should be promptly initiated if the symptoms are persistent, increasing, or causing impairment.
  
• Don't depend on arbitrary guidelines (Nace, Brown, ed., 1995, p. 173).

Dual diagnosis treatment is a complex series of interventions addressing substance use, personality issues, and Axis I psychiatric disorders. It is not mental health psychotherapy that supposedly will have an indirect impact on the addiction; it is not traditional alcohol and drug treatment that does not concurrently treat or adjust for psychiatric disorders and/or personality disorders. Dual diagnosis treatment is the accessible, comprehensive, integrated, and coordinated focus on both psychiatric and substance abuse disorders (Dual Diagnosis Subcommittee, 1995). It is concurrent and flexible treatment utilizing the knowledge base and intervention techniques of both mental health and addiction.

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