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Regular Article |
Received September 6, 2000; revised February 9, 2001; accepted February 17, 2001. From the New York State Psychiatric Institute, New York, New York. Address correspondence to Dr. Aviram, New York State Psychiatric Institute, Division of Neuroscience-Unit 42, 1051 Riverside Drive, New York, NY 10032.
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ABSTRACTS |
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 Top ABSTRACTS INTRODUCTIONINTEGRATING TREATMENT FOR...THE PSYCHOTHERAPY CONTEXTSTAGES OF TREATMENTTREATMENT CONSIDERATIONSTHE LIMITS OF RELAPSE...CONCLUSIONSREFERENCES |
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Key Words: Attention-Deficit/Hyperactivity Disorder • Substance Use
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INTRODUCTION |
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The psychosocial difficulties that people with ADHD encounter are thought to contribute to increased vulnerability to drug and alcohol use; for example, they may use drugs or alcohol to enhance peer acceptance or to avoid painful feelings.7 Adults with substance abuse problems and undiagnosed ADHD often report that they realized something was wrong with them throughout their lives but attributed their difficulties to the drug use. In the worst cases, these individuals create a lifestyle that accommodates to the difficulties they encounter. They may have learned to establish lives with few demands or responsibilities and resigned themselves to superficial and conflictual relationships. They may have stopped working and have few time commitments, which both allows them to avoid acknowledging the difficulties that stem from ADHD and permits ongoing drug use. Unfortunately, this pattern promotes a feeling of hopelessness about developing satisfying and productive lives. When the diagnosis of ADHD is made, they gain an organizing framework from which to understand a lifetime of interpersonal and work-related difficulties.
Although medications have been extremely helpful in reducing restlessness and increasing attentional capacities, there are special considerations with this comorbid population. Levin et al.8 suggest that desipramine and bupropion may be good alternative medications to avoid the risk of abuse that is present with methylphenidate. They add that sustained-release methylphenidate could be used with individuals who do not respond to an antidepressant.
Several papers have addressed medication treatment with this population; however, we will focus here on psychotherapeutic efforts to manage this comorbid condition. As part of a multimodal treatment,9 it is necessary to target psychological and social factors that have become problematic. In the past, the professional literature rarely discussed psychotherapeutic interventions that addressed the psychosocial difficulties arising from ADHD. More recently, however, several papers have appeared that discuss the need for incorporating therapy into the treatment plan.9,10 In our experience, the relationship that develops with a therapist helps these individuals overcome their resistance to treatment and medications—and such resistance can otherwise lead to early withdrawal from treatment.
It is imperative that an accurate assessment for this comorbid condition occur early in treatment. The results of such an assessment have implications for the course of illness and provide an opportunity to anticipate specific problems that may arise with this population. If comorbidity is not addressed effectively, it is likely to limit the benefit of treatment. For example, Carroll and Rounsaville11 found that despite more treatment exposure, cocaine abusers with childhood ADHD did worse in treatment than cocaine users with no history of ADHD. Further support for the importance of an accurate assessment was reported by Wilens et al.,12 who found that ADHD adults had slower remission rates and experienced longer duration of PSUD in comparison with non-ADHD adults. In our experience it is not so much that patients with comorbid ADHD and PSUD will have unique symptoms that are not found with either disorder independently. Rather, they present with a greater number of symptoms, that may have greater severity, than if the patient did not have the comorbid condition. For example, the combination of PSUD and ADHD is likely to exacerbate impulsivity. Similarly, distractibility can be explained by either disorder, but given that it was present in childhood, it is likely to become more pervasive because of drug use.
In all likelihood, clinicians have been treating this comorbid condition without directing specific attention to the interaction of ADHD and drug use. During the treatment of comorbid ADHD and PSUD, the prevailing wisdom stresses the importance of first getting the substance abuse under control.13 Ideally, this would permit an accurate evaluation of ADHD symptoms, which could then be addressed. However, a pragmatic treatment should attempt to target overlapping symptoms stemming from both conditions as they arise in therapy. Our treatment team has used a brief cognitive-behavioral treatment (12–18 sessions) within a research context to treat both conditions simultaneously. We have found that relapse prevention7 (RP) is well suited to treat sets of symptoms that are common to both conditions. Relapse prevention was developed to treat alcohol dependence and subsequently adapted to treat other addictive behaviors. In treating substance abuse, RP addresses the goal of abstinence by developing self-control strategies and healthier coping skills. The patient learns and repeatedly practices these skills to work on problem areas such as overcoming impulsive behavior and managing uncomfortable affect. Similar goals are considered when treating patients with ADHD and a comorbid PSUD.
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INTEGRATING TREATMENT FOR COMORBID ADHD AND PSUD |
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In other words, RP helps individuals with substance abuse problems, but, importantly, RP is appropriate for individuals with comorbid PSUD and ADHD because it addresses development of impulse control and tolerance of physiological discomfort. Similarly, RP encourages the patient to begin to recognize internal cues and external triggers. These are important tasks for individuals with substance abuse problems, as well as those with ADHD.
Furthermore, strategies that involve writing things down, or making lists about positive and negative consequences of using drugs, model effective behaviors that help individuals cope with abstaining from drugs. Such strategies target poor organizational skills and poor memory, symptoms that are common in people with substance abuse problems and also in individuals with ADHD. Given that organization and memory tasks may be difficult for individuals with ADHD,14 the clinician should take the opportunity to create lists during sessions.
In addition, problem-solving is a cornerstone of many cognitive-behavioral treatment programs and is emphasized as a strategy for anticipating and defusing situations before they develop into problems that could trigger substance use. Individuals with comorbid ADHD and PSUD are especially likely to have deficits in problem-solving abilities, and therefore repeated practice with this strategy not only helps with reducing risk for relapse, but also builds needed skills that they can apply in other areas of their lives.
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THE PSYCHOTHERAPY CONTEXT |
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In therapy, clinicians should keep in mind that adults with comorbid ADHD and PSUD tend to have limited coping skills. Often, stressful situations that require attention to details or thinking through alternative behaviors could become overwhelming, and in response, they may use drugs in an effort to cope with or avoid their current problems. Furthermore, these individuals have learned to look as if they are paying attention, but in fact they could easily become distracted. Therefore, the session provides a perfect context to practice techniques and rehearse new strategies to cope with urges to use drugs. The in-session practice is particularly important with this group given that they may have difficulty completing practice exercises between sessions. In addition, the therapist must continually seek examples that integrate the interaction of ADHD and substance use, since this may increase the patient's interest in session material. Such creative efforts by therapists are all the more important with these patients because of their limited attention span and tendency toward boredom.
Patients frequently use many "techniques" to help control their urges to use drugs without realizing that they are doing so. Identifying and encouraging more consistent use of these attempts at self-control can help patients feel more confident about their ability to resist drug use urges and cravings. Patients need help in recognizing their "self-talk,"—cognitions that can either lead to a decision to use drugs or can help to mediate the urge to use. In addition, patients may already be engaging in positive coping behaviors such as attempting to stay busy with multiple activities as a way to distract themselves from cravings. When patients make these efforts, it is helpful to label them as active coping strategies or techniques and offer praise for using them. This labeling helps encourage patients' active engagement with the struggle to stay abstinent, rather than leaving them with a passive feeling that their drug use or abstinence "just happens for no particular reason."
The following is an example of an approach that highlights the patient's strengths and labels these behaviors as coping skills and techniques. This vignette is an example of this process early in treatment:
THERAPIST: How did you manage not to use yesterday when you had the craving?PATIENT: I just started to wash the dishes, and I told myself that I am not going to use anyway so forget it.
THERAPIST: That's great, you know, what you are describing are real skills and strategies. And you use them naturally. I want to label them, give them a name, so you can know exactly what you do when you do it. That way you have more control and you can use this skill consciously in the future when you are craving. So, we'll call what you did when you started to wash dishes a distracting activity, and when you told yourself that you are not going to use, let's call that positive self-talk.
Most patients will be able to describe self-statements that they have employed to try to cope with cravings. When patients are unable to identify self-statements because of an "automatic thinking process," there is an opportunity to discuss the importance of becoming aware of what is being said "in their head." Presenting skills in this way acknowledges that these individuals have skills already and that they can be successful when using them. In therapy with these individuals, the clinician is continually adjusting the focus from the substance abuse to symptoms that are associated with ADHD. Whenever possible, it is helpful to draw a connection between drug use behavior and ADHD behaviors.
In the following section we elaborate stages of treatment and general themes that may emerge when treating individuals with comorbid ADHD and PSUD in psychotherapy.
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STAGES OF TREATMENT |
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In the middle phase of treatment the focus is directed at barriers to abstinence, such as ambivalence about stopping drug use or continued exposure to triggers that are easily avoided. Patients are taught to anticipate high-risk situations and to recognize decisions that lead to drug use. Patients' failure to use these skills and strategies do not necessarily stem from ADHD, but if coping abilities are not well implemented, then it is possible that the skills needed to succeed are poorly developed as a result of the ADHD. The therapist should address this factor as contributing to the patient's difficulties in using the coping skills learned in sessions.
The termination phase of treatment continues to strengthen the skills that have been developed and highlights how those skills are being used in new as well as familiar situations. An overview of progress should be initiated by asking the patient what he or she believes has changed over the course of treatment. Therapist and patient should address disappointment about what has not been accomplished and discuss how the skills that the patient has mastered can be implemented beyond treatment to reach additional goals.
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TREATMENT CONSIDERATIONS |
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PT.: In bed I was thinking about using the next day.TH.: So you were setting it up the night before.
PT.: I believe you are right, I was setting it up the night before.
TH.: Did something happen even...? (therapist was cut off from adding, "...before going to bed to get you thinking about it").
PT.: You're right, I was thinking about it the night before and I wanted to use the next day real bad.
TH.: Do you remember you told me about how your wife complains that you cut her off? You know about this yourself, too. It just happened between us. Did you notice?
PT.: I did, but I was thinking about how I was already thinking about using the night before, and I just said it.
TH.: That is important to recognize, but also how it is hard to stop yourself sometimes when you get something in your head.
PT.: You're right, it is.
TH.: That is what I mean about the ADHD part that makes it hard to pull back. For us to recognize this is important, because I think that this is like the times when you get the idea to use; it's hard to pull back, and that is what you need to do, but first you have to recognize that you're having a craving.
In the vignette above, impulse control was associated with both interpersonal behavior and drug use behavior. This shows how the ADHD symptom of verbal impulsivity provides an opportunity to discuss impulsivity as it relates to drug use. The impulsive experience was first associated with interpersonal difficulties that have been highlighted by his wife, and so it is personally meaningful. When impulsive behavior was evident in the session, the therapist was able to associate this behavior with drug use behavior, which may also be enacted impulsively.
Distractibility
For many adults with ADHD, the primary difficulty is distractibility.16 This can be manifested, for example, as an inability to keep one's mind on conversations, as being easily distracted because of an inability to filter out extraneous stimuli, or as frequent forgetfulness.17 This limited ability to focus makes the task of maintaining abstinence more difficult. During the recovery process, the need to remain vigilant about self-talk, automatic thinking, or cravings and triggers is a constant challenge. These individuals have lapses in their ability to concentrate, which can lead to drug use episodes. One patient described this experience in the following way:
PT.: I go a week and it's like I lose focus and I use again. I always use again.TH.: That's a pattern that you are recognizing and that gives us a chance to plan to break that routine.
PT.: It's like I don't think about it any more and that's when I use.
TH.: When you try to stay focused on that one thing, how to continue not using, and then you lose focus, we need to think about that as an ADHD problem. It might be even harder for you to keep focused than someone without ADHD who is trying to stop.
Again, the patient is discussing a behavior that is directly associated with drug use but is also very much a symptom of ADHD. Distractions can lead to drug use because the patient has an especially difficult time staying focused on the goal of abstinence. This could be a convenient rationalization, or the goal could be blocked out of awareness in an effort to avoid other difficulties. Drug use may have been the most immediate solution for avoidance of problems, but the patient may not be aware that the drug use is serving this purpose. Thus, distractibility, which is a common symptom of ADHD, may have taken on other meanings and functions that need to be explored in therapy. By understanding more about this behavior, the patient gains a greater ability to overcome it.
Avoidance
The interaction between ADHD and PSUD complicates the treatment process by exacerbating symptoms. Patients may use their comorbid diagnosis as a way to rationalize their drug use and other problems. The interaction between ADHD and drug use in both causing and avoiding problems thus needs to be carefully explored. In some cases patients may try to use the ADHD diagnosis as a way to account for the difficulties associated with drug use instead of acknowledging the role that drug use plays in causing problems. Others may have turned to drugs as a way to avoid experiencing the discomfort and shame stemming from problems created by ADHD. These patients may minimize the contribution of ADHD and explain their difficulties as solely caused by their drug use.
The challenge for therapists is to identify the links between the cognitive, behavioral, and physiological symptoms associated with ADHD and those associated with drug use. The patient's creation of a vicious circle, in which limitations stemming from ADHD along with negative self-worth may lead to drug use that further limits coping abilities and thus maintains the drug use, must be countered in treatment by providing tangible coping skills and strategies, many of which are incorporated in the relapse prevention model.
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THE LIMITS OF RELAPSE PREVENTION |
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A short-term treatment that makes use of relapse prevention can provide important skills that offer alternative ways to cope with physical and emotional discomfort. As such, a treatment that uses a relapse prevention model is a good initial treatment, especially for managing the drug use problems. However, the chronic nature of both ADHD and substance abuse could compromise the effectiveness of newly learned coping skills and strategies unless the long-standing intrapersonal and psychosocial issues are addressed in treatment.
Other approaches have also been effective in treating substance abuse. These include Motivational Enhancement Therapy,18 Community Reinforcement,19 and 12-step programs,20 although the usefulness of these programs for treating comorbid ADHD and PSUD needs to be examined. Couple therapy and group therapy are also commonly employed to treat either substance abuse or ADHD, although, again, the effectiveness of these treatment modalities for this comorbid condition has not been discussed in the literature.
Unfortunately, relapse is common following treatment for substance abuse regardless of the presence of ADHD, but the dually diagnosed patient is even more at risk and is likely to require a longer treatment that incorporates a focus on developmental factors that may be maintaining drug use behavior.
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CONCLUSIONS |
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In the early stages of treatment, as patients try to cope with substance abuse, their ADHD symptoms are prominent and they struggle to avoid drugs that would otherwise be used to distract them from this discomfort. Relatedly, Hoegerman et al.21 reported that newly abstinent substance abusers may have impaired attention that is comparable to levels of performance by adults diagnosed with ADHD in childhood. This finding implies that as substance abuse is reduced, individuals with comorbid ADHD and PSUD may experience symptoms that could be misinterpreted as a worsening of ADHD symptoms.
Similarly, when patients try to cope with ADHD they may feel that their drug urges are getting stronger. They must work hard to overcome typical ADHD symptoms that distract them from being mindful of the skills and strategies that can help them to cope with their cravings. This dilemma may be further complicated if medications for ADHD have been prescribed. There is some evidence suggesting that after initiating medication for treating ADHD, patients may experience things so differently that, paradoxically, they may feel uncomfortable.9 In either case the focus of treatment is the same; the effort is to increase impulse control and affect tolerance, while at the same time building skills to stay focused on tasks such as problem-solving or learning to attend to internal cues or thoughts. During early recovery, either disorder can become an excuse for drug use and avoidance of the difficulties inherent in trying to change.
The clinician's goal is to help patients integrate their understanding of difficulties stemming from both conditions. The rationale of treatment for this comorbid condition is to reduce and stop drug use in order to be able to use coping strategies for ADHD more effectively. The challenge in working with this population is that the coping strategies that patients need to learn in order to stop drug use are the very strategies that they need to master to overcome ADHD, and therefore these patients are starting treatment with limited abilities. The question of which problem to address first is often dependent on the difficulties presented by the particular patient, but abstinence should be a central focus of the initial treatment. Although cessation of drug use may be presented as the focus of treatment, the behavior that is changing is very much associated with ADHD.
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ACKNOWLEDGEMENTS |
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REFERENCES |
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TopABSTRACTSINTRODUCTIONINTEGRATING TREATMENT FOR...THE PSYCHOTHERAPY CONTEXTSTAGES OF TREATMENTTREATMENT CONSIDERATIONSTHE LIMITS OF RELAPSE...CONCLUSIONSREFERENCES |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ALL ISSUES | SEARCH | TABLE OF CONTENTS |
