Treatment Strategies for Persons with Cooccurring SubstanceRelated Disorders and Cluster B Personali

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Treatment Strategies for Persons with
Co-occurring Substance-Related Disorders and
Cluster B Personality Disorders

• Arthur J. Cox, DSW, LCSW, Donna L. Burton,
  Ed.M.
• 2005 National Forum on Clinical Skill
• Building for Co-occurring Disorders
• September 22-23, 2005 Orlando, Florida

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COD Resources

• SAMHSAs Co-Occurring Center for Excellence at
  www.coce.samhsa.gov
• Co-Occurring Dialogues Discussion List
  Membership is free and unrestricted and can be
  done by sending an e-mail to dualdx_at_treatment.org.
  
• Co-Occurring State Incentive Grants (COSIG) and
  Policy Academies see SAMHSA website for
  information at www..samhsa.gov
• Reports (see COCE website)

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COCE Core Products and Services

• The COCE Web Site www.coce.samhsa.gov
• Overview papers, technical reports, and other
  products
• Technical Assistance
• Direct requests to
• Email samhsacoce_at_cdmgroup.com
• Phone [phone]
• Meetings and conferences
• Pilot evaluation of the Performance Partnership
  Grant (PPG) measure

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• Im a frayed knot!

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Diagnostic Coding

• Axis I clinical disorders (for our purposes
  substance-related disorders and major mental
  illnesses including mood, anxiety, and psychotic
  disorders) other conditions that impact the
  clinical picture
• Axis II personality disorders mental
  retardation
• Axis III general medical conditions,
  particularly those that are ongoing, or have
  historically impacted the clinical picture such
  as a closed-head trauma
• Axis IV problems with psychosocial functioning,
  and environmental problems
• Axis V Global Assessment of Functioning
  (typically, two numbers are assigned according to
  the GAF scale to assess the current level of
  functioning and the highest level over the past
  year)

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Causative Factors and InfluencesAs Compared with
Axis I Major Mental Disorders

• Biological (Axis I Disorders -- Axis II
  ?? )
• genetic predisposition
• chemical imbalance
• Psychological
• individual personality, lifespan development
• cognitive and emotional strengths and
  weaknesses
• use / choice of psychological defenses
• Social
• socially learned behaviors
• environmental stressors
• influence of risk vs. protective factors

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AXIS II Personality Disorders

• There are a total of eleven personality
  disorders, coded on Axis II, according to the
  DSM-IV-TR, and they break down this way
• Cluster A the odd / eccentric disorders which
  include Paranoid, Schizoid and Schizotypal
  Personality Disorders
• Cluster B the dramatic / erratic disorders
  which include Antisocial, Borderline, Histrionic
  and Narcissistic Personality Disorders
• Cluster C the anxious / fearful disorders which
  include Avoidant, Dependent and
  Obsessive-Compulsive Personality Disorders
• Personality Disorder Not Otherwise Specified
  (NOS) does not meet the specific criteria for
  any one disorder, but with features of more than
  one disorder that are chronic and problematic
• see TIP 42, p.349

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Cluster B Personality Disorders and
Development(diagram a)
Development of Borderline/Histrionic Personality
Disorders
Development of Antisocial/Narcissistic
Personality Disorders
Typical Development
self
self
self
world and others
world and others
world and others
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Cluster B Personality Disorders and
Development(diagram b)
Development of Antisocial/Narcissistic
Personality Disorders
Development of Borderline/Histrionic Personality
Disorders
self
self
world and others
world and others
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Cluster B Personality Disorders and
Development(diagram c)
Typical Relationship No Disorder
self
other
11
Cluster B Personality Disorders and
Development(diagram d)
Borderline Personality
self
other
other
self
self
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Cluster B Personality Disorders and
Development(diagram e)
self
other
Antisocial Personality
self
other
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Cluster B Personality Disorders Abbreviated
Diagnostic Criteria

• Antisocial Personality Disorder
• (characterized by three or more of the following)
• unlawful behavior repeated acts that are
  grounds for arrest
• deceitfulness, lying, use of aliases, or
  conning others for pleasure or profit
• impulsivity failure to plan
• recklessness disregard for the safety of self
  and others
• irresponsibility poor work history failure
  to meet financial obligations
• lack of remorse indifference to hurting,
  mistreating, or violating the rights of others
  rationalizing having done so
• Note The individual is at least 18 with a
  history of Conduct Disorder before age 15.

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• Narcissistic Personality Disorder
• (characterized by five or more of the following)
• grandiose sense of self importance
• preoccupations with fantasies of success,
  wealth, power, brilliance, beauty, or ideal love
• beliefs related to being special or unique or
  only understood by other unique people
• requires excessive admiration
• sense of entitlement expects favorable
  treatment or compliance with own wishes
• lack of empathy unwilling to identify with
  the feelings and needs of others
• envious of others expects that others will be
  envious of him/her
• arrogant behavior haughty attitude

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• Borderline Personality Disorder
• (characterized by five or more of the following)
• frantic efforts to avoid real or imagined
  abandonment
• unstable, intense relationships extremes of
  idealization and devaluation
• identity disturbance unstable self image
• impulsivity which is self-damaging, or
  deprecating
• recurrent suicidal threats or gestures
  self-destructive or self- mutilating behavior
• affective instability and reactivity of mood
• chronic feelings of emptiness
• inappropriate, intense anger difficulty
  controlling anger
• transient, stress-related paranoid ideation or
  severe dissociative symptoms

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• Histrionic Personality Disorder
• (characterized by five or more of the following)
• discontent when not the center of attention
• inappropriately sexually seductive or
  provocative
• rapidly shifting or shallow expressions of
  mood and affect
• excessively impressionistic style of speech,
  often lacking in detail
• exaggerated expressions theatrical displays
  of emotion and self-dramatization
• easily influenced by others and circumstances
• considers relationships to be more intimate
  than they are
• criteria condensed from the DSM-IV

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• Differential Diagnosis
• Symptoms of Substance-Related Disorders and
  Symptoms of Cluster B Personality Disorders

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Strategies for Treatment and Recovery
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another word about antisocial and borderline
personalities

• Considering assessment. (TIP 42, p. 356, 364)
• How do characteristics of these disorders, world
  views and general levels of functioning affect
  treatment scenarios? (TIP 42, p. 350 Figure
  D-6)
• Key Issues and Concerns of Treatment (TIP 42, p.
  355, 359, 362,)
• Strategies, Tools and Techniques (TIP 42, p.
  355, 364, 367)

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• Spilling your guts is just exactly
• as charming as it sounds.
• 
  Fran Lebowitz
• Social
  Studies (Random House)

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• Energy
• Options
• Structure