Psychiatric Difficulties
| PERSONALITY ISSUES —Glen Treisman, MD, Associate Professor of Psychiatry and Behavioral Sciences,
and Director, AIDS Psychiatry Services, Johns Hopkins School of Medicine, Baltimore
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| Perspectives on psychiatric disorders: 1) psychiatric disorders as disease; “for every twisted thought, there’s a
twisted neuron”; all problems belong in Diagnostic and Statistical Manual of Mental Disorders (DSM) and operationalized
criteria for everything in psychiatry; debatable because life experiences (eg, rape) can result in
psychologic problems but do not affect neuronal function; speaker views psychologic problems as “problems
of the software” (ie, how individuals respond to experiences); 2) psychiatric disorders associated with attachment
to mother; both perspectives fail at explaining personality disorder
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| Borderline personality: patients with personality disorder use medical resources but do not improve; views during
1930s—borderline patients halfway between psychotic and neurotic; psychotic people have injuries or
developmental delays early in life and develop schizophrenia and bipolar disorder because of problem with
attachment to mother; neurotic people had problems with attachment to mother, but did not develop trouble
until later; no supporting data; optimistic idea, but results in conflicting theories; blames patients and misses
sick people for troubled people
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| Personality dimensions: personality as endowment (similar to, eg, height); introverts—consequence-averse; future-directed;
function-directed; extroverts—reward-directed; feeling-directed; “now”-directed; in patients
with disorders, personality style interferes with function; patients can be too introverted and too extroverted
to function in certain environments; drug addiction lifestyle requires moral flexibility; extroverts not personality
disordered unless required to perform introverted tasks (eg, health care); extroverts have difficulty with
future-oriented and consequence-avoidance behaviors; vulnerable to behaviors that feel good but are harmful
(eg, excessive alcohol use)
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| Management: reframe therapy as rewards instead of consequences; patients require encouragement, support,
and positive reinforcement; extroverted patients often try to manipulate physicians to obtain harmful prescriptions;
set rules to help patients; help patients decrease use of drugs; give enough drugs to last for 2
days; after 1 wk, give enough drugs to last 1 wk; if patient does well for 2 wk (ie, does not lose prescriptions,
discloses physician visits), give 1-mo supply; if patient fails regimen and runs out of drugs early, return
to dispensing drugs every other day; inconveniencing patient changes behavior
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| Stability-instability axis: unstable—“neurotic”; emotions change easily; stable—emotions relatively unchanged;
interact with unstable patients by setting firm limits and pushing for treatment plan; patients often confuse
“need” for “want,” “can’t” (ie, unable to) for “won’t” (ie, do not want to), and “think” for “feel”; when extroverts
say “can’t,” “need,” or “think,” asking “do you mean won’t?”, “do you mean feel?”, or “do you mean
want?” shapes patients’ behavior
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| Addictive behaviors: driven by personality because addiction associated with feelings; difficult to communicate
with patients because discussing function, consequence avoidance, and future conflicts with discussing
present time, feelings, and rewards; management—1) set firm limits and declare rules (eg, “my practice is always
going to work to get you better, but we are not going to work to make you comfortable with being
sick”); 2) set expectations of patients and reliably apply rewards when patients comply; 3) therapeutic optimism
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| DRUG-SEEKING BEHAVIOR —Dr. Treisman
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| Drug-seeking patients: function destroyed by medications, but life more comfortable; possible to rehabilitate
people to restore function and comfort; opiates most commonly sought drugs; clonidine—opiate-naive animals
do not self-administer clonidine, but opiate-experienced animals do; has addiction liability and street
value; patients also seek opiate-extenders (eg, promethazine [Phenergan]) and anticholinergics
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| Reinforcing drugs: self-administration—animals work (eg, pull lever) to receive drugs (eg, opiates, stimulants,
sedative hypnotics, dronabinol [Marinol]); animals exposed to opiates work to get clonidine; animals do not
work to get Phenergan or anticholinergics, but some people do
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| What drives drug-seeking behavior? extroversion; determine differential diagnosis; addiction; depression; patient
vulnerable and manipulated; some patients conditioned by experience with medical system to seek
medications; problems in life
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 | Reinforcement: behavior encouraged by surroundings; probability of behavior can be increased or decreased,
depending on immediate consequence; behavior shaped in subtle ways; positive reinforcement—eg, animal
pulls lever and receives candy; punishment—eg, animal pulls lever and receives electric shock; consequence
stops behavior (aversive); extinction—eg, animal pulls lever but does not receive candy;
negative reinforcement—eg, animal receives electric shock every 5 sec and when animal pulls lever, electric
shock removed; positive and negative reinforcement often seen together; complex behaviors conditioned
in small steps
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| Positive reinforcement: continuous—maximum rate of behavior (eg, cocaine addiction); rate of behavior increased
by, eg, giving medication every time patient presents to office; intermittent—longevity of behavior
(eg, gambling); behavior persists by, eg, giving medication only occasionally
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| Conditioning: pain, anxiety, and other psychologic symptoms can be conditioned; manipulations can increase
firing rate of pain receptors in brain; some patients with pain syndrome experience more pain when conditioned
to experience more pain; people can be conditioned to change behavior
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| Addiction as disease: experiments—1) patient with disease (eg, lupus or schizophrenia) placed in chair and receives
electric shock whenever symptoms present; symptoms do not lessen, but increase; 2) patient with alcoholism
placed in chair with favorite bottle of liquor in front of him; touching bottle results in receiving
electric shock; results show patient’s fingers burned but bottle full; addiction not simply disease, but has disease-like
biologic component; addiction more complicated than choice; abnormally driven, biologically
driven behavior; biologic and volitional abnormality causes annoyance when patients relapse; in most diseases,
patients receive medications and improve, but addiction requires patients to take action and rehabilitative
treatment
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| Motivated behavior: environmental exposure provides opportunity for certain behavior; influenced by positive or
negative reinforcement; positive feedback loop—some behaviors (eg, eating) release dopamine; cravings followed
by behavior result in satiation; dangerous because can result in excessive behavior, but drives behaviors necessary
for survival; control of cycles driven by drugs and rewards can be lost; cycles regulated by other cycles that demand
attention and shape behavior (eg, cycles associated with spouses and work); increased drug behavior increases
disruption of cycles; depression, life state, and temperament influence whether person tries drugs; other
psychologic conditions influence strongly how vulnerable people are
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| Alcoholism: genetic factors—in some people, use of alcohol results in high release of dopamine (significant reinforcement);
some people take years to develop alcoholism (eg, drinking occasionally to relieve anxiety
gradually activates cycle)
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| How to determine whether person addicted: person uses drugs excessively when allowed to; person may decrease
use in response to consequences, but 14% to 18% of people continue; when patients exhibit manipulative behaviors
and start seeking drugs, recognize transition and intervene; management—set firm limits; discuss
function; think about treatment goals; continuing long-term narcotics may be reasonable if patient’s goal is to
use only enough narcotics to be functional; use controlled consistent amount and ask patient for proof of improved
function (eg, attend Narcotics Anonymous [NA] meetings and work, 40 hr of structured activity
weekly); care plan designed for rehabilitation and function; positive reinforcement; therapeutic optimism
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| PAIN PATIENTS WITH SUBSTANCE ABUSE PROBLEM —Robert V. Brody, MD, Clinical Professor,
Medicine and Family & Community Medicine, University of California, San Francisco, School of Medicine,
and Chief of Pain Consultation Clinic, San Francisco General Hospital
|
| Introduction: physicians fearful of being deceived by patients with opiate addiction; lack of standard approach
to assess or treat clinical issues (eg, management of pain and opiate withdrawal); physicians avoided engaging
patients about key complaints and expressed discomfort and uncertainty in approach; patients sensitive to
possibility of poor medical care, equating physician inconsistency with intentional mistreatment
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| Physical dependence: common with opiates, benzodiazepines, barbiturates, antihypertensive medications, and corticosteroids;
managed by weaning patients from agent
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| Tolerance: poorly understood phenomenon; literature shows tolerance not viewed as important issue
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| Addiction: primary chronic disease with genetic, psychosocial, and environmental factors; characteristics—
impaired control over drug use; compulsive use; continued use despite harm; cravings for drug
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| Pseudoaddict: patient with chronic painful condition who requires opioids to function; demanding, drug seeking,
and manipulative; determine effect and watch behavior after giving patient proper dose of pain medication
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| Screening for addiction vs chronic severe pain: look at behavior; behaviors that may indicate addiction—visiting
several doctors; obtaining analgesics from drop-in settings (determine whether patient can arrange relationship
with one physician); increased number of prescribed doses or increased frequency; seeking early refills;
losing prescriptions or medications; forging prescriptions; obtaining drugs from street sources; demanding
drugs with higher street value; hoarding unused medications; nonadherence to recommended nonopioid treatment
or evaluation; insistence on rapid-acting formulations or intramuscular or intravenous routes of administration
(patients can be weaned from agents); supplementing analgesics with alcohol or other psychoactive
drugs; using analgesics to relieve symptoms other than pain (eg, anxiety)
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| Screening for substance abuse: questions to ask—“have you ever tried to stop or cut down?” “has your family or
anyone complained or discouraged use?” “have you ever had trouble with driving?” “did you ever get into
trouble at work or school?” “have you ever been injured while under the influence?” urine toxicology screening
useful
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| Management: realize physicians and patients need to trust each other; patients and physicians have rights; make
explicit patients’ and physicians’ responsibilities; establish rules early and be prepared to enforce them; if
rules violated, do not abandon patient (help patient get treatment for substance abuse)
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Educational Objectives
| The goal of this program is to educate the listener about personality issues and drug-seeking behavior. After
hearing and assimilating this program, the participant will be better able to:
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| 1. Describe dimensions of personality disorders.
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| 2. Explain motivated behaviors.
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| 3. Screen patients for addictive behavior.
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| 4. Improve relationships between patients and health care providers.
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| 5. Counsel patients about substance abuse and addiction.
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Suggested Reading
Ben-Shahar O et al: Prolonged daily exposure to i.v. cocaine results in tolerance to its stimulant effects. Pharmacol
Biochem Behav 82:411, 2005; Friedel RO: Early sea changes in borderline personality disorder. Curr Psychiatry
Rep 8:1, 2006; Grush OC: A Review of: "Borderline Personality Disorder Demystified-An Essential Guide
for Understanding and Living with BPD. By Robert O. Friedel, M.D.". Ann Clin Psychiatry 18:75, 2006; Koob
GF et al: Plasticity of reward neurocircuitry and the 'dark side' of drug addiction. Nat Neurosci 8:1442, 2005;
Kumari V et al: Personality predicts brain responses to cognitive demands. J Neurosci 24:10636, 2004; Lusher J
et al: Analgesic addiction and pseudoaddiction in painful chronic illness. Clin J Pain 22:316, 2006; McCaffery
M et al: On the meaning of "drug seeking". Pain Manag Nurs 6:122, 2005; Mobbs D et al: Personality predicts
activity in reward and emotional regions associated with humor. Proc Natl Acad Sci U S A 102:16502, 2005;
Nieuwenhuis S et al: Knowing good from bad: differential activation of human cortical areas by positive and
negative outcomes. Eur J Neurosci 21:3161, 2005; Spanagel R et al: Addiction and its brain science. Addiction
100:1813, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed.
For this issue, the faculty reported nothing to disclose.
Dr. Treisman spoke in Lancaster, Pennsylvania at the 29th Annual Fall Family Practice Review, presented September
25-30, 2005, by Temple University School of Medicine and Lancaster General Hospital. Dr. Brody
spoke in San Francisco at Pain Management and End-of-Life Care, presented June 9-10, 2005, by the University
of California, San Francisco, School of Medicine. The Audio-Digest Foundation thanks the speakers and the
sponsors for their cooperation in the production of this program.
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