Bipolar Patients with Comorbid Substance Use Disorders; Diagnostic and Treatment Considerations:

Comorbidity of bipolar disorder (BD) and alcoholism and substance use disorders (SUDs) represents a serious public health problem and a major challenge to treatment systems.

Bipolar disorder is among the top causes of disabilities worldwide, and reportedly the fourth leading mental illness as a source of disease burden in established market economies. Large epidemiologic surveys in the United States have consistently confirmed a high association between bipolar disorder and SUDs. The Epidemiological Catchments Area Study reported bipolar I and bipolar II disorders as having the highest association with SUDs when compared with any other major psychiatric disorder.

The prevalence of lifetime alcohol abuse or dependence in persons with bipolar I disorder and bipolar II disorders were found to be 46%, and 39.2% respectively.

Similarly, the National Comorbidity Survey reported respondents with mania to be 8 to 9 times more likely to have an additional lifetime disorder of drug or alcohol dependence compared with the general population. The most recent and largest epidemiologic survey of more than 42,000 respondents in the United States, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), reported that mania and hypomania were associated with very high rates of SUDs. Those with mania were 6 times more likely to have alcohol dependence and 14 times more likely to have drug dependence over the past 12 months.

Research from; Psychiatric Annals, Volume 38 · Number 11, NOVEMBER 2008

There is a long-recognized association between alcohol consumption and aggressive behavior. But does aggression and hostility continue into sobriety?

This study was designed to examine aggression in a group of socially well-adapted recovered alcoholics.

The question addressed was whether the treatment, together with long-term abstinence from alcohol, could reduce aggression and hostility in recovered alcoholics.

Sixty four male stable alcoholics with at least 3 years sobriety were compared with 69 non-alcoholics. Neither group had any other psychological problems.

Both groups were given a questionnaire on general characteristics as well as aggressive and hostility traits.

After a 3-year abstinence, men from the recovering alcoholics group displayed greater signs of hostility and covert aggression. They were different from non-alcoholics on measures for indirect aggression, irritability, negativism, suspicion, resentment, and guilt.

Research report; Ziherl S, Cebasek Travnik Z, Kores Plesnicar B, Tomori M, Zalar B. Trait aggression and hostility in recovered alcoholics. Eur Addict Res 2007; 13(2): 89-93.

Postural sway among abstinent alcoholics can be improved up to a point

Excessive sway during quiet standing is a common and significant consequence of chronic alcoholism, even after prolonged sobriety, and can lead to fall-related injury and even death.

A new study of residual postural instability in alcohol-abstinent men and women shows that alcoholics improve with prolonged sobriety, but the improvement may not fully erase the problem of instability.

Results will be published in the March 2010 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

“Caricatures depict acutely intoxicated individuals with a stumbling, weaving, wobbly gait,” said Edith V. Sullivan, professor in the department of psychiatry and behavioural sciences at Stanford University School of Medicine and corresponding author for the study. “With sobriety, gait and balance become stable. However, even with prolonged sobriety, people with long-term chronic alcohol dependence can have difficulty in standing upright. Their balance can be marked by sway that exceeds what most of us experience while standing still in one place, especially with feet together and hands down by one’s side, that is, without use of natural stabilizing factors.”

Sullivan said that quantifying the sway can be accomplished by using a force plate to record the sway path in fractions of an inch over fractions of seconds during quiet standing. This provides “sway path tracking” as well as measurement of body tremor, which are micro-movements often reflective of central nervous system damage that can be found both in Parkinson’s disease and alcoholism.

Researchers used a “force platform” to measure postural sway – with and without stabilizing conditions from touch, vision and stance – in 34 alcoholic men, 15 alcoholic women, 22 control men, and 29 control women. They then analyzed “biomechanical control mechanisms” that indicate skeletomuscular control over balance, which – under normal circumstances – means the muscles, joints, and skeletal structure are working synergistically, in a give-and-take manner.

“Results show the sway paths of alcoholics are longer and cover a wider area than those of controls for a given time,” said Sullivan. “However, it is important to note that the standing stability of sober alcoholics can be improved by using stabilizing factors. These factors can include simple aids like turning a light on in a dark room, touching a banister while walking down a flight of stairs, or walking or standing with feet apart rather than with ankles close together.”

Sullivan added that the disproportionately greater sway in the anterior-posterior (front-to-back) direction than the medial-lateral (side-to-side) direction that they found is associated with chronic alcoholism as well as pathology of the anterior superior vermis of the cerebellum.

“This part of the brain is often disturbed in alcoholism, and lesions there, whether or not a result of alcoholism, can cause impairment in gait and balance,” she said. “It is interesting to note that while alcoholic men and women can quell their imbalance with stabilizing factors, alcoholic women do not necessarily improve to control levels.” Until more is known about improving this deficit, Sullivan suggested that people who are at risk utilized simple strategies to stabilize balance and to avert falls.

Predictors of changes in alcohol-related self-efficacy over 16 years

Self-efficacy is a robust predictor of short- and long-term remission after alcohol treatment. This study examined the predictors of self-efficacy in the year after treatment and 15 years later.

A sample of 420 individuals with alcohol use disorders was assessed five times over the course of 16 years.

Predictors of self-efficacy at 1 year included

• improvement from baseline to 1 year in heavy drinking,
• alcohol-related problems,
• depression,
• impulsivity,
• avoidance coping,
• social support from friends, and
• longer duration of participation in mutual-help Alcoholics Anonymous (AA).

Female gender, more education, less change in substance use problems, and impulsivity during the first year predicted improvement in self-efficacy over 16 years.

Clinicians should focus on

• keeping patients engaged in self-help of AA,
• addressing depressive symptoms,
• improving patient’s coping, and
• enhancing social support

during the first year and reduce the risk of relapse by monitoring individuals whose alcohol problems and impulsivity improve unusually quickly.

Research; Predictors of changes in alcohol-related self-efficacy over 16 years. John McKellar Ph.D, Mark Ilgen Ph.D., Bernice S. Moos B.A. and Rudolf Moos Ph.D. J Subst Abuse Treat. 2007 Nov 23.

See also;

• AA and Treatment Work Better Together
• Brief-TSF can assist patients cease alcohol consumption.
• AA Offers Recovery Not Religion

Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment by Marc A. Schuckit Read more about this title…

Tolerance Equals More Consumption for Older Problem Drinkers

Adults over age 60 who have alcohol problems tend to drink more than their younger counterparts, probably because they have developed greater tolerance for alcohol, according to researchers at Ohio State University.

Science Daily reported that a study found that alcohol-dependent individuals over age 60 consumed an average of more than 40 drinks per week, compared to 25-35 among younger people with similar levels of dependence.

Researchers said that older drinkers developed tolerance for alcohol, meaning they had to drink more to get the same effects.

The older drinkers also reported more monthly binge-drinking episodes.

“A combination of high levels of drinking and the physiological effects of aging are particularly problematic for older adults,” noted researcher Linda Ginzer.

Younger Americans were still more likely to have drinking problems than older Americans, however.

Researchers found that binge drinking was more common among Americans classified as alcohol abusers than among those who were heavy drinkers but not seen as problem drinkers.

“That suggests binge drinking may be a better measure of problem drinking than just the total amount of drinks someone has per week,” Ginzer said.

The findings, drawn on findings from the National Epidemiologic Survey on Alcohol and Related Conditions, were unveiled at a recent meeting of the Gerontological Society of America. From; Join Together Online.

• See also;
• Brief-TSF is designed to address these issues.
• Alcohol & Medication Interactions
• Physical effects of alcohol on women

An ongoing process: A qualitative study of how the alcohol-dependent free themselves of addiction through progressive abstinence

Abstract (provisional)

Background Most people being treated for alcoholism are unable to successfully quit drinking within their treatment programs.

In few cases do we know the full picture of how abstinence is achieved in Taiwan.

We tracked processes of abstinence in alcohol-dependency disorders, based on study evidence and results.

This research explores the process of recovery from the viewpoint of the alcohol-dependent.

Methods Semi-structured interviews were conducted in two different settings, using purpose sampling, during 2003-2004.

The data were analyzed using content analysis.

Participants were 32 adults (men and women) , purposefully selected from Alcoholics Anonymous group and a psychiatric hospital in North Taiwan.

Results We found that the abstinence process is an ongoing process, in which the alcohol-dependent free themselves of addiction progressively. This process never ends or resolves in complete recovery.

We have identified three stages of change in the struggle against alcoholism:

1. the Indulgence, Ambivalence and Attempt (IAA) cycle, in which the sufferer is trapped in a cycle of attempting to give up and failing;
2. the Turning Point, in which a Personal Nadir is reached, and
3. the Ongoing Process of abstinence, in which a constant effort is made to remain sober through willpower and with the help of support groups.

We also discuss Influencing Factors that can derail abstinence attempts, pushing the sufferer back into the IAA cycle.

Conclusion This study provides important points of reference for alcohol and drug service workers and community healthcare professionals, casting light on the abstinence process and providing a basis for intervention or rehabilitation services.

An ongoing process: A qualitative study of how the alcohol-dependent free themselves of addiction through progressive abstinence Mei-Yu Yeh, Hui-Lian Che and Shu-Mei Wu BMC Psychiatry 2009, 9:76doi:10.1186/1471-244X-9-76.

Click file below to download full report.

Elder Alcohol Intervention

Abstract:

Current US census estimates predict that by the year 2020, 18% of the population will be 65 years or older. As most adults in this age group have health care needs, it is vital that clinicians are competent in identifying and intervening in the most common health issues among older adults.

The article in this issue by Blazer and Wu again reminds us that alcohol use, including binge drinking, is common among older adults and that despite popular culture, alcohol misuse does not disappear as one ages. As noted in the article, the findings are very consistent with other epidemiological literature.

Blazer and Wu found that 13% of men and 8% of women reported at-risk drinking and that 14% of men and 3% of women reported binge drinking.

This is not to suggest that many older drinkers have a diagnosis of alcohol dependence. However, identification and delivery of appropriate interventions focused on those with regular heavy use of alcohol and binge drinking provide an opportunity for clinicians to help improve overall health, promote independence, and reduce health care costs.

One of the strengths of the Blazer and Wu study is its large, diverse sample, which seems well representative of the population seen in outpatient primary care and mental health clinics.

Including subjects ages 50-64 was helpful for comparison, as it showed drinking was greater in the younger group than in the older individuals. The study variables used to assess alcohol use for patients with low-risk, at-risk, and binge drinking were clinically appropriate, as they were set to detect those who might be most at risk for harm related to their drinking.

One of the findings of great importance was that alcohol misuse in this population was a marker for other problems, including;

• illicit drug use,
• tobacco use, and
• misuse of prescription medications.

The data demonstrate differences between at-risk and binge drinkers across various demographic groups. For instance, the variables associated with men and women who reported binge drinking suggest that those at risk from each sex tended to be from different backgrounds.

These associations can help target at-risk populations, but our overall goal is to screen all of our geriatric patients.

Research; Alcohol Misuse Among the Elderly: An Opportunity for Prevention, Sarah Mathews, David W Oslin. The American Journal of Psychiatry. Oct 2009. Vol. 166, Iss. 10; p. 1093 (3 pages)

Domestic violence

Intimate partner violence against women is prevalent and is associated with poor health outcomes.

Understanding indicators of exposure to intimate partner violence can assist health care professionals to identify and respond to abused women. This study was undertaken to determine the strength of association between selected evidence-based risk indicators and exposure to intimate partner violence.

In this cross-sectional study of 768 women aged 18-64 years who presented to 2 emergency departments in Ontario, Canada, participants answered questions about risk indicators and completed the Composite Abuse Scale to determine their exposure to intimate partner violence in the past year.

Results: Intimate partner violence was significantly associated with

• being separated,
• in a common-law relationship or
• single
• depression
• somatic symptoms
• having a male partner who was employed less than part time, or
• having a partner with an alcohol or
• drug problem

Each unit increase in the number of indicators corresponded to a four-fold increase in the risk of intimate partner violence; women with 3 or more indicators had a greater than 50% probability of a positive score on the Composite Abuse Scale.

Intimate partner violence was not associated with pregnancy status.

Specific characteristics of male partners, relationships and women’s mental health are significantly related to exposure to intimate partner violence in the past year. Identification of these indicators has implications for the clinical care of women who present to health care settings. (Source: Open Medicine

Alcohol hospital admissions hide individual tragedies, say doctors (issued Tuesday 22 Jul 2008)

The new government figures released today (Tuesday 22 July 2008) revealing that 811,000 people in England were admitted to hospital with alcohol misuse problems in 2006 hide the individual tragedies that hospital frontline staff see day in day out, said the British Medical Association.

The BMA’s Head of Science and Ethics, Dr Vivienne Nathanson, added:

“While this figure is rightly very frightening and shocking, it also hides the hundreds and thousands of individual tragedies that doctors witness every day. Alcohol misuse is related to over 60 medical conditions including heart and liver disease, diabetes, strokes and mental health problems – it costs the NHS millions of pounds every year and is linked to accidents and street violence.

The truth is there is nothing glamorous about drinking too much alcohol – it wrecks health, lives and families.

“The BMA will be responding in full to the government’s consultation on alcohol and we will certainly be backing tough action like introducing mandatory regulation and labelling and restricting ‘happy hours’ and irresponsible drinks promotions . There can be no more softly, softly approach. The access and affordability of alcohol must be tackled head on.”

Full story at; British Medical Association, The professional association for doctors

See also;

• If you have healthcare training this manual may help.
• Science of Addiction
• Early or Adaptive Stage of Alcoholism
• Types of Dysfunctional Families

Understanding and Counseling Persons With Alcohol, Drug, and Behaviorial Addictions by Howard Clinebell Read more about this title…

Psychotherapy is a unique relationship, a kind of connection that is unlike any other kind of relationship a person has in their life. In some ways, it can be more intimate than our most intimate relationships, but it also paradoxically values a vestige of professional distance between therapist and client.

Therapists, alas, are just as human as the clients they see and come with the same human foibles. They have bad habits, as we all do, but some of those habits have the very real potential of interfering with the psychotherapy process and the unique psychotherapy relationship.

So without further ado, here are twelve things you wish your therapist didn’t do — some of which may actually harm the psychotherapeutic relationship.

1. Showing up late for the appointment.
2. Eating in front of the client.
3. Yawning or sleeping during session.
4. Inappropriate disclosures.
5. Being impossible to reach by phone or email.
6. Distracted by a phone, cell phone, computer or pet.
7. Expressing racial, sexual, musical, lifestyle and religious preferences.
8. Bringing your pet to the psychotherapy session.
9. Hugging and physical contact.
10. Inappropriate displays of wealth or dress.
11. Clock watching.
12. Excessive note-taking.

Full story and expansion of these annoyances at PsychCentral

See also;

• Be there for them when they’re ready
• Brief-TSF is designed to as adjunctive therapy for anti-craving medication.
• Maturity of Mind Through a Spiritual Awakening