Psychiatric Aspects of the Disease of Addiction

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Psychiatric Aspects of the Disease of Addiction

• By R. Jeffrey Goldsmith MD
• Cincinnati VAMC
• Professor of Clinical Psychiatry Director of
  Addiction Fellowships

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Countertransference

• Before we identify pathology in other, know
  thyself, cultural and personal stigma
• Literally it means reaction to others
  transference to us
• Primary Codependence
• Secondary Codependence
• Probably closer to projective identification
• Splitting

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Ideology

• Are we twelve step Abstinence Based?
• What are our acceptable outcomes?
• Are we Harm Reduction based?
• What are our acceptable outcomes?
• What outcome data are we willing to accept?
• Can we practice empirically-based medicine?

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Self-Medication Hypothesis

• Good face validity
• Way we operate
• What we hear our patients say
• Not supported by research
• Ignores the biology of addictions
• Now what?
• Harder for clinician
• How to listen to your patients?

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Cartwright, Spratley, et al

• Research in the 70s and 80s about changing
  attitudes of clinicians in mgmt of alcoholism
• 5 factors evaluated
• Self esteem
• Role knowledge
• Role expectation to take care of
• Expertise available to clinician
• Role satisfaction
• Well supervised, intensive experience

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Sensitization and Motivation

• Hijacking the motivation center
• Permanent changes in animals
• No affect
• Anticipation and the urge to use

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Psychosocial Interventions with Addictions

• The person is a different person motivationally
• Disavowal of this change
• Must know what you deny on some level
• Disavowal is conscious
• Levels of disavowal
• Different dynamics of each level

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Stages of Change

• Precontemplation
• Contemplation
• Action
• Maintenance
• Relapse

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Psychosocial Factors

• Empathy and bonding
• Intention and loss of control
• Traditional Values
• Models of behavior
• Monitoring
• Alternative immediate rewards

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Quality of Life Measures with PTSD

• No more bed days or violence
• More unemployed (adjusted OR 3.3)
• More reduced health status (adj. OR 3.3)
• More diminshed well-being (adj. OR 3.6)

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National Vietnam Veterans Readjustment Study

• Approximately 20 y post-discharge
• 15 continue to suffer from PTSD
• 11 continue to suffer from an alcohol-related
  d/o
• 75 of PTSD male vets had lifetime alc disorder
• 22 of active PTSD had current alc
  abuse/dependence

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Three Models

• Shared Stressor Hypothesis
• Consequences of PTSD Hypothesis
• Shared Vulnerability Hypothesis
• Factor analysis shows Avoidance, Arousal, and
  Re-experiencing Clusters

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Shared Stressor Model

• High combat exposure 4X PTSD cf. low-moderate
  exposure
• High exposure showed no more alc-related
• Twin study suggested high exposure more likely
  PTSD but not more alc-related

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Consequence of PTSD Model

• Not supported by data
• High consumption during service and low
  self-confidence related to high PTSD in Vietnam
  Vets
• Level of drinking not related to level of combat
  exposure

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Shared Vulnerability Model

• Environmental or Genetic
• PTSD vets had more alc sibs than dep/anxious
  controls
• Vietnam Vet Twin Registry found genetic component
  for both alcohol and PTSD
• Strong evidence for genetic component to both
  alcohol and PTSD

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Unique Environmental Influences vs. Genetic
Influences

• UEI gtgtGI for exposure to combat
• UEI GI for alcohol use
• UEI gtGI for PTSD Factors
• 57 Variance for combat exposure and volunteering
  explained by genetic variance

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Summary for SAPTSD

• Not sure if conduct disorder, antisocial,
  impulsivity, thrill seeking associated
• UEI influence combat exposure, alcohol use,
  expression of PTSD sx
• Not necessarily the same for each

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Summary Continued

• Not support the shared stressor model
• Combat exposure only associated with
  re-experiencing
• Association lessens over time
• Not support the consequences of PTSD model
• Environmental influences specific to PTSD sx not
  associated with alc-related d/o
• Does support the shared vulnerability model
• Genetics that leads to exposure also leads to
  PTSD sx and alc use

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Addiction--Vulnerability
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Caspi A et al. Science. 2003301386-389
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Caspi, Science. 2003301386-389
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Caspi Science. 2003301386-389
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Addiction--Vulnerability
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Caspi Science. 2002297851-854
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Caspi Science. 2002297851-854