Anne Landheim

Gender Differences in the Prevalence of Symptom Disorders and Personality Disorders among Poly-Substance Abusers and Pure Alcoholics

Objective: Gender differences in the prevalence of Axis I and II disorders in poly-substance abusers and pure alcoholics and between these two groups are explored. Method: A consecutive sample (n = 260) of in- and out-patients from two Norwegian counties were assessed by CIDI (Axis I disorders) and MCMI-II (Axis II disorders). Results: Major depression, post-traumatic stress disorder (PTSD), and eating disorders were significantly more prevalent in women than in men. A significantly higher prevalence of antisocial, passive-aggressive, and borderline personality disorders (PD) was observed among poly-substance abusers, whereas pure alcoholics were found to have dependent PDs more often. Female poly-substance abusers differed significantly from all other substance abusers by suffering more often from major depression, simple phobia, PTSD and borderline PD. Male poly-substance abusers more often presented antisocial PD and less often Cluster C disorders than all other substance abusers. Female pure alcoholics more often had major depression and Cluster C disorders than all other substance abusers. Male pure alcoholics presented less often with Axis I disorders, major depression, and PTSD, but more often with Cluster A disorders, in particular schizoid PD, than all other substance abusers. Conclusion: The pattern of comorbid disorders is clearly different between male and female poly-substance abusers and pure alcoholics. This implies that these four subgroups have important differences in their treatment needs.

What Characterizes Substance Abusers Who Commit Suicide Attempts? Factors Related to Axis I Disorders and Patterns of Substance Use Disorders

Objective: The frequency of suicide attempts and clinical characteristics of attempters among poly-substance abusers and alcoholics were examined. Methods: A consecutive sample (n = 260) of in- and outpatients from two Norwegian counties were assessed by Composite International Diagnostic Interview (Axis I disorders), Millon’s Clinical Multiaxial Inventory (Axis II disorders) and the Norwegian National Client Assessment Form. When analysing the association between suicide attempters and the range of predictor variables, logistic regression analysis was conducted. Results: Almost half (47%) of the sample reported lifetime suicide attempts; significantly more frequently in poly-substance abusers (58%) than alcoholics (38%). A substance use disorder with duration of ≧15 years and an early onset (<18 years of age) were independently associated with being a suicide attempter after controlling for Axis I disorders. In addition, eating disorders, agoraphobia and major depression were strongly and independently associated with being a suicide attempter. Conclusion: Attempts at preventing suicidal behaviour should not ignore the suicide risk among poly-substance abusers. In addition, prevention of suicidal behaviour demands a treatment programme focusing concomitantly on both addictive behaviour and comorbid psychiatric disorders.

Axis I and II disorders as long-term predictors of mental distress: a six-year prospective follow-up of substance-dependent patients

BackgroundA high prevalence of lifetime psychiatric disorders among help-seeking substance abusers has been clearly established. However, the long-term course of psychiatric disorders and mental distress among help-seeking substance abusers is still unclear. The aim of this research was to examine the course of mental distress using a six-year follow-up study of treatment-seeking substance-dependent patients, and to explore whether lifetime Axis I and II disorders measured at admission predict the level of mental distress at follow-up, when age, sex, and substance-use variables measured both at baseline and at follow-up are controlled for.MethodsA consecutive sample of substance dependent in- and outpatients (n = 287) from two counties of Norway were assessed at baseline (T1) with the Composite International Diagnostic Interview (Axis I), Millons Clinical Multiaxial Inventory (Axis II), and the Hopkins Symptom Checklist (HSCL-25 (mental distress)). At follow-up (T2), 48% (137/287 subjects, 29% women) were assessed with the HSCL-25, the Alcohol Use Disorders Identification Test, and the Drug Use Disorders Identification Test.ResultsThe stability of mental distress is a main finding and the level of mental distress remained high after six years, but was significantly lower among abstainers at T2, especially among female abstainers. Both the number of and specific lifetime Axis I disorders (social anxiety disorder, generalized anxiety disorder, and somatization disorder), the number of and specific Axis II disorders (anxious and impulsive personality disorders), and the severity of substance-use disorder at the index admission were all independent predictors of a high level of mental distress at follow-up, even when we controlled for age, sex, and substance use at follow-up.ConclusionThese results underscore the importance of diagnosing and treating both substance-use disorder and non-substance-use disorder Axis I and Axis II disorders in the same programme.

“Life on Hold”: A Qualitative Study of Patient Experiences with Outpatient Commitment in Two Norwegian Counties

In recent decades, outpatient commitment orders have been increasingly used in the follow-up of persons with serious mental disorders. Most studies on outpatient commitment orders have focused on compliance and consumption of health care services; there is little research on the content of outpatient commitment orders from a patient perspective. The aim of this study is to examine patients’ experiences of living with outpatient commitment orders, and is based on qualitative interviews with 16 persons in two Norwegian counties. The data were analysed using a constructivist, interpretive approach to the grounded theory method. The main finding was that patients with outpatient commitment orders felt that their lives were on hold. The feeling of being seen only as patients prevented them from taking responsibility for their own lives. The medical context was perceived as an obstacle to recovery and transition to a more normal life. Patients’ daily lives were dominated by the agenda set by health care providers and many said they were subjected to control measures that resulted in a reduced quality of life. However, informants also spoke of positive experiences as outpatient commitment order patients, such as feeling safe and secure and having easy access to health care staff and services.

Walking the fine line: Self-reported reasons for substance use in persons with severe mental illness

Many theoretical models have been proposed to explain the relationship between severe mental illness (SMI) and substance use. Because many of these are contradictory quantitative American studies, a qualitative, exploratory study of a Scandinavian sample may offer a new perspective. The aim of the study is to explore reasons for substance use through analysis of the participants’ experiences. A qualitative study with semistructured interviews was used. Purposeful sampling (N=11) of patients with substance use disorder (SUD) and SMI, who were included in assertive community treatment teams, was completed. Inclusion criteria are increased quality of life or increased general functioning, and decreased substance use, after a minimum of 12 months in treatment. Reasons given for using substances were categorized as (a) controlling the symptoms of mental illness, (b) counteracting medication side effects, or (c) balancing the ambiguity. The conclusion is that the study findings mainly support secondary substance use models in explaining the comorbidity of SMI and substance use. However, there is some support for the traditional self-medication hypothesis (SMH), iatrogenic vulnerability, and the supersensitivity model. This may be because the majority of the study participants reported having a mental illness with subsequent substance use. The expressed ambivalence to substance use also lends some support to bidirectional models.

Early and late onset groups of substance misusers: Differences in primary and secondary psychiatric disorders

Aim: To identify clinical differences between early onset (EO; at age <18 years) and late onset (LO; at age 18 years or older) groups of patients with substance use disorders (SUD). Sample: A naturalistic, consecutive sample of DSM‐IV alcohol‐dependent (n=156) and polysubstance‐dependent patients (n=131) from three outpatient and six inpatient public programmes in two neighbouring counties in Norway. Methods: Primary axis I disorders (occurring at least 1 year before any SUD) and secondary axis I disorders (occurring at least 1 year after any SUD) were assessed with the Composite International Diagnostic Interview (CIDI); axis II disorders were assessed with Millon Clinical Multiaxial Inventory (MCMI)‐II. Results: In the EO group, significantly more clients had primary anxiety disorders, (especially social phobia and post‐traumatic stress disorder (PTSD)) and antisocial, borderline and passive‐aggressive personality disorders (PDs), and fewer had dependent and compulsive PDs. EO strongly predicted polysubstance misusers (vs. pure alcoholism) and had more frequent secondary PTSD. Results were generally identical when a cut‐off point of 25 years was used. The average EO patients SUD manifested 6 years before psychiatric treatment, whereas the LO patients had been in psychiatric treatment for 2 years before the SUD. Conclusion: EO/LO allowed the delineation of two clinical subgroups and provided information about possible prevention strategies, early interventions and treatment.

‘Responsible, but Still not a Real Treatment Partner’: A Qualitative Study of the Experiences of Relatives of Patients on Outpatient Commitment Orders

The aim of this study was to explore relatives’ experiences when their family member is under an outpatient commitment order. A descriptive and exploratory approach was used based on qualitative interviews with 11 relatives. The relatives felt they had responsibility for the patient, but experienced a lack of recognition for their contribution to the treatment. Relatives paid little attention to coercion, but were more concerned about whether the follow-up care improved the patients social functioning. They further reported an unmet need for information and guidance from healthcare staff to improve cooperation in the patients care and treatment.

Searching for Sobriety: How Persons with Severe Mental Illness Experience Abstaining from Substance Use

Individuals diagnosed with severe mental illness (SMI) are more vulnerable to substances than are other people. Many people with SMI tend to attain full remission of their substance use, but others relapse frequently. There is more research on the reasons for substance use than on the reasons for abstaining among these individuals. Information from the latter may contribute to a better understanding of how individuals with SMI experience abstaining from substance use. Objective: The aim of this explorative study was to examine experiences of abstaining from substances of persons diagnosed with SMI. We examined both the reasons given and the requirements and strategies used when abstaining. Methods: A qualitative study with semi-structured interviews was conducted, and a descriptive and explorative design was applied. This study included a purposeful sample of 11 patients with SMI and substance use being treated by assertive community treatment teams. Results: The main reasons for quitting substance use were social relationships and meaningful activities. The stated requirements and strategies used in the search for sobriety were detachment towards people and places, positive thinking, controlling feelings and emotions, and fear of dependency. Conclusion: Our results are consistent with those from other qualitative studies on the importance of social relationships and meaningful activities as expressed reasons for abstaining. The strategy of actively avoiding a former adverse milieu to reach sobriety is consistent with findings from one similar study. The strategies of fear of adverse consequences, positive thinking, and controlling feelings and emotions found in the present study have not been reported by other qualitative studies.

Alexithymia in alcohol dependent patients: Gender differences, associations with craving and dependence severity

Debates over models of professional training have occurred in several clinical disciplines, including psychology. Currently, clinical competencies often form the backbone for the accreditation of such training programmes, with sample domains including ethical and legal issues, assessment, intervention, and experience with a diversity of clients across cultures and the lifespan. This paper presents data from a large Australian research project on clinical psychology training. We review key models for clinical competencies in the international literature and report on results of a survey of students undertaking clinical training as to the methods of assessment used in their training programmes. Results showed that direct competency assessment was less commonly used than expected from the stated accreditation standards. One factor behind the results may be that ways to assess such competencies remain elusive. In this paper, models of clinical competency assessment are offered, with practical considerations for embedding this and data on student outcomes when such a programme is firmly in place.Assessment of Fitness to Practise (FTP) guidelines within clinical psychology training programmes requires balancing the individual student’s right to pursue their vocation of interest and the rights of others with whom that person comes in contact, most especially clients. The past decade has seen an international growth in policies related to formal FTP assessment built into clinical training programmes leading to professional qualifications. We draw on data from a large Australian research project on clinical psychology training in Australia. This national survey of 35 clinical psychology programmes explored views from both clinical directors and clinical students. Recommendations on realistic ways to move forward in this area are offered.

“Care or control?”: a qualitative study of staff experiences with outpatient commitment orders

PurposeOutpatient commitment orders are being increasingly used in many countries to ensure follow-up care of people with psychotic disorders after discharge from hospital. Several studies have examined outpatient commitment in relation to use of health care services, but there have been fewer studies of health professionals’ experiences with the scheme. The purpose of this study was to examine health professionals’ experiences with patients subject to outpatient commitment.MethodsThis was a focus group study using a descriptive and exploratory approach. The study was based on three focus group interviews with a total of 22 participants. Data were analysed using qualitative content analysis.ResultsThe study showed that health professionals had a positive attitude towards outpatient commitment and considered it necessary for patients with psychosis who lacked insight and did not collaborate on treatment. At the same time their attention to patients’ lack of insight could lead to a paternalistic approach more than measures to enhance patient autonomy. This challenged their therapeutic relationship with the patient.ConclusionHealth professionals found it difficult to combine control with therapeutic care, but gave greater emphasis to patients’ need for treatment and continuity of care than to their autonomy. This dilemma indicates a need to discuss whether increased attention to patients’ autonomy rather than insight into their illness would improve treatment cooperation and reduce the use of coercion.