The relationship between early maladaptive schemas and eating-disorder symptomatology among individuals seeking treatment for substance dependence

Numerous studies have examined early maladaptive schemas (EMS) and their relationship to psychological disorders, including eating disorders (EDs) and substance use disorders (SUDs). However, to date, there are no empirical investigations that have examined the relationship between EMS and EDs among individuals seeking treatment for substance use. In an attempt to further elucidate this relationship, the purpose of the current, exploratory study was to examine the relationship between EMS, ED symptomatology (i.e. bulimia and binge-eating but not anorexia) and substance use and to directly compare EMS among individuals with and without a probable ED diagnosis. Participants were 387 men and 132 women seeking residential treatment for substance use. Results demonstrated that 11 of the 18 EMS were significantly associated with ED. Moreover, patients with a probable ED scored significantly higher than patients without a probable ED on 8 of the 18 EMS. Results suggest that EMS are prevalent among individuals with ED pathology seeking treatment for substance use. Thus, treatment programs could potentially benefit from the assessment and treatment of EMS among dually diagnosed patients. Given the exploratory and preliminary nature of the study, continued research is needed to further examine the relationship between EMS, EDs and substance use.     

Experiential Avoidance and Bulimic Symptoms among Men in Residential Treatment for Substance Use Disorders: A Preliminary Examination

There has been a growing focus on identifying factors that underlie and maintain bulimic symptoms and substance use disorders (SUDs), as both are associated with high mortality and poor clinical outcomes. Experiential avoidance has been an area of interest within both the eating disorder and SUD fields, as it is a robust risk factor for both disorders. No known research has examined the relationship between experiential avoidance and bulimic symptoms in a SUD treatment-seeking sample. Moreover, the extant literature has focused exclusively on female samples. The purpose of this exploratory study was to examine the relationship between bulimic symptoms and experiential avoidance within an understudied population: men in treatment for a SUD. Three separate hierarchical regression analyses were conducted to examine the following relationships: (1) experiential avoidance and bulimic symptoms; (2) experiential avoidance and alcohol use and problems; and (3) experiential avoidance and drug use and problems. Results demonstrated that, controlling for alcohol and drug use and problems, experiential avoidance was significantly associated with bulimic symptoms. Experiential avoidance was also significantly associated with alcohol use and problems and drug use and problems. These findings are preliminary and future research is needed to further examine this relationship.     

Dispositional Mindfulness and Aggression Among Women in Residential Substance Use Treatment

There is a large literature on substance misuse and interpersonal aggression, including aggression perpetrated by women in treatment for substance misuse. There is also a growing body of literature on mindfulness and substance use, as well as mindfulness and aggression. However, to date, there has been little research on whether dispositional mindfulness is associated with increased aggression among women in treatment for substance misuse. The current study, therefore, examined whether dispositional mindfulness was associated with aggression, above and beyond substance use and demographic characteristics, in women in residential substance misuse treatment (N = 137). Results showed that lower dispositional mindfulness was associated with increased aggression (physical, verbal, and aggressive attitude). Moreover, this relationship between dispositional mindfulness and aggression remained even after controlling for alcohol problems, drug problems, and age, all known predictors of aggression. Our results provide the first empirical evidence that dispositional mindfulness is negatively associated with aggression in women in treatment for substance misuse. Pending replication, this could have important implications for treatment. Specifically, mindfulness-based interventions may prove helpful for the concurrent treatment of substance misuse and aggression.     

Emergency Department Utilization for Substance Use-Related Disorders and Assessment of Treatment Facilities in New York State, 2011–2013

Background: Annually, 1.8 million New York (NY) residents experience substance use disorders (SUDs). Even though emergency departments (EDs) continue to experience high numbers of SUD-related visits, only 15% receive treatment. Objectives: This study estimates hospital-based EDs rates for SUDs in the State of New York. Also, the geographic distribution of substance use treatment centers and EDs are mapped to correlate utilization with access to care. Methods: The 2011–2013 Healthcare Cost and Utilization Project’s NY State Emergency Department Database provided information on utilization of services in EDs, charges, diagnoses, and discharge, as well as patient demographic variables. All patients within NY who had visited the ED for SUDs comprised the study population. Geographic mapping of EDs and substance abuse treatment centers at the county-level is based on data from the National Emergency Department Inventory and National Survey of Substance Abuse Treatment Services, respectively. Results: A total of 492,419 ED visits for SUDs were reported through 2011–2013. Despite NY’s Medicaid expansion in 2012, ED visits increased in 2013. About $856 million was spent in treating SUDs in EDs, with average charge of $1,764 per visit. Conclusions/Importance: Alcohol and drug-induced mental disorders are increasingly prevalent in New York’s EDs. There is a need to develop health policies and programs to improve access to care for SUDs in urban states.     

PTSD symptom presentation among people with alcohol and drug use disorders: Comparisons by substance of abuse

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) commonly co-occur, and there is some evidence to suggest that PTSD symptom clusters are differentially related to various substances of abuse. However, few studies to date have compared PTSD symptom patterns across people with different types of SUDs, and fewer still have accounted for the presence of comorbidity across types of SUDs in understanding symptom patterns. Thus, in the current study, we use a treatment-seeking sample of people with elevated symptoms of PTSD and problem alcohol use to explore differential associations between past-year SUDs with active use and PTSD symptoms, while accounting for the presence of multiple SUDs. When comparing alcohol and drug use disorders, avoidance symptoms were elevated in those with alcohol use disorder, and hyperarousal symptoms were elevated in those who had a drug use disorder. In the subsample with alcohol use disorder, hyperarousal symptoms were elevated in people with co-occurring cocaine use disorders and numbing symptoms were elevated in people with co-occurring sedative/hypnotic/anxiolytic use disorder. These findings provide evidence for different symptom cluster patterns between PTSD and various types of SUDs and highlight the importance of examining the functional relationship between specific substances of abuse when understanding the interplay between PTSD and SUDs.     

The Relationship Between Generalized Anxiety Symptoms and Treatment Dropout Among Women in Residential Treatment for Substance Use Disorders

Background: Generalized anxiety disorder (GAD) co-occurs with substance use disorders (SUDs) at an alarmingly high rate, and the presence of anxiety is associated with an increased risk for relapse to substance use following treatment. Furthermore, comorbid SUDs and other forms of psychopathology are associated with an increased risk for leaving treatment against medical advice (AMA). Objective and Method: Research has yet to examine whether the presence of GAD symptoms is associated with leaving treatment AMA in SUDs populations. Thus, the current study sought to address this important gap in the literature by examining this relationship among a sample of 122 women in residential treatment for SUDs. Results: Results demonstrated that GAD symptoms were significantly associated with the decision to leave treatment AMA after controlling for age, education, problematic alcohol and drug use, and depression symptoms. Conclusions/Importance: Our finding indicates the potential importance of assessing and targeting GAD in treatment for SUDs, which may increase treatment compliance.     

A Randomized Controlled Trial of a Mindfulness and Acceptance Group Therapy for Residential Substance Use Patients

Background: Substance use disorders are understood as a chronically relapsing condition that is difficult to treat. However, in recent years there have been promising developments in the treatment of substance use disorders, specifically with interventions based on mindfulness and acceptance and commitment therapy. Little research has examined whether these types of interventions may positively impact residential substance use treatment outcomes. Objectives: Thus, in the current study we developed and examined, in a randomized controlled trial, a 4-week, eight-session, adjunctive mindfulness and acceptance group therapy for patients in residential substance use treatment. Our primary outcomes were substance use cravings, psychological flexibility, and dispositional mindfulness at treatment discharge. Methods: Patients (N = 117) from a private residential substance use facility were randomized to receive the adjunctive mindfulness and acceptance group or treatment-as-usual. Patients were assessed at treatment intake and at discharge from a 28–30-day residential program. Results: Although treatment groups did not statistically differ at discharge on any primary outcome, small effect sizes favored the mindfulness and acceptance group on cravings and psychological flexibility. Conclusions/Importance: Continued research is needed to determine whether the addition of mindfulness and acceptance-based interventions improve outcomes long term following residential substance use treatment.     

Longitudinal investigation of the impact of anxiety and mood disorders in adolescence on subsequent substance use disorder onset and vice versa

Objective

A large body of epidemiological research indicates that anxiety and mood disorders are highly comorbid with substance use disorders (SUDs). However, longitudinal research regarding their temporal relations is limited. The goal of this study was to assess whether emotional disorders (i.e., anxiety and mood disorders) predict the onset of SUDs, whether SUDs predict the onset of emotional disorders, or both.

Method

The current study used data from baseline assessment (N = 627) and four years of follow-up assessments from the NU/UCLA Youth Emotion Project to examine this question.

Results

In line with the self-medication hypothesis of emotional disorder/SUDs comorbidity, anxiety and unipolar mood disorders at baseline assessment were associated with later onsets of SUDs. In particular, social anxiety disorder (SAD) at baseline predicted onset of alcohol use disorders and PTSD predicted the onset of all SUDs. SUDs did not predict any anxiety or unipolar mood disorders with the exception that alcohol use disorders predicted the onset of obsessive compulsive disorder (OCD).

Conclusions

These findings, as well as the clinical implications and future directions for research, are discussed.     

Differential roles of thought suppression and dispositional mindfulness in posttraumatic stress symptoms and craving

Exposure to traumatic events often results in severe distress which may elicit self-medication behaviors. Yet, some individuals exposed to trauma do not develop post-traumatic stress symptoms and comorbid addictive impulses. In the wake of traumatic events, psychological processes like thought suppression and mindfulness may modulate post-traumatic stress and craving for substances. We examined the differential roles of mindfulness and suppression in comorbid post-traumatic stress and craving among a sample of 125 persons with extensive trauma histories and psychiatric symptoms in residential treatment for substance dependence. Results indicated that thought suppression, rather than extent of trauma history, significantly predicted post-traumatic stress symptom severity while dispositional mindfulness significantly predicted both post-traumatic stress symptoms and craving. In multiple regression models, mindfulness and thought suppression combined explained nearly half of the variance in post-traumatic stress symptoms and one-quarter of the variance in substance craving. Moreover, multivariate path analysis indicated that prior traumatic experience was associated with greater thought suppression, which in turn was correlated with increased post-traumatic stress symptoms and drug craving, whereas dispositional mindfulness was associated with decreased suppression, post-traumatic stress, and craving. The maladaptive strategy of thought suppression appears to be linked with adverse psychological consequences of traumatic life events. In contrast, dispositional mindfulness appears to be a protective factor that buffers individuals from experiencing more severe post-traumatic stress symptoms and craving.     

The Relation Between Moment-to-Moment Mindful Attention and Anxiety Among Young Adults in Substance Use Treatment

Background: A growing body of research has examined the intersection of mindfulness and substance use, and a large body of research has examined the relation between mindfulness and anxiety. Unfortunately, no research has been conducted on the relation between mindfulness and anxiety symptoms among young adults (i.e., 18–25 years old) in treatment for substance use. The purpose of the current study was to examine the relation between one facet of mindfulness, moment-to-moment attention, and anxiety (panic and generalized anxiety) among young adults in treatment for substance use. Methods: Preexisting patient records from a residential substance use treatment center for young adults were reviewed (N = 148). Patient records were examined from May 2012 to August 2013, which represented all young adult patients admitted to the residential treatment facility during this time. Results: Findings demonstrated that moment-to-moment mindful attention was associated with symptoms of panic disorder and generalized anxiety disorder even after controlling for gender, age, education, alcohol use, drug use, and the shared variance in generalized and panic symptoms. There were no gender differences in moment-to-moment mindful attention. Conclusions: These findings provide preliminary evidence that moment-to-moment mindful attention is associated with panic and generalized anxiety in young adults in substance use treatment. Combined with previous research on mindfulness-based interventions among adults in substance use treatment, research should examine the efficacy of mindfulness-based interventions for young adults in substance use treatment.     

Identifying patterns of co-occurring substance use disorders and mental illness in a jail population

Although the co-occurrence of mental health and substance use disorders (SUDs) is well documented among correctional populations, less explored are the actual patterns that exist between specific SUDs and additional mental health disorders in combination. This study examines prevalence and correlates of psychiatric comorbidity in incarcerated men who screened positive for a SUD and the ability of a practical structured interview to document diagnostic indications of SUDs and co-occurring disorders. Comprehensive Addictions and Psychological Evaluation (CAAPE) interview data from 176 substance-dependent male inmates incarcerated in a local jail facility were analyzed. The most common substance dependence diagnoses were for alcohol (81%) and cocaine (35%). Posttraumatic stress disorder (PTSD) was the most common co-occurring mental health condition (55%), followed by antisocial personality disorder and major depressive episodes (51% each). Patterns related to the presence of PTSD and major depressive episodes accounted for a vast majority of inmates with both two and three diagnostic indications. Cronbach's alphas for the individual CAAPE diagnostic subscales ranged from 0.74 to 0.97. The design and implementation of treatment programs for substance-dependent inmates must consider co-occurring mental health issues. Several of the diagnostic categories evinced a bimodal pattern of responses in terms of severity. Negative correlations among many of the SUDs suggest that those with a greater level of severity involving some substances are less likely to manifest dependence and high severity for other substances. The observed Cronbach's alphas for the various subscales demonstrated acceptable preliminary support for the use of the CAAPE as a practical instrument in indentifying co-occurring disorders in a jail setting.     

Comorbidity of substance use disorders and other psychiatric disorders among adolescents: evidence from an epidemiologic survey

This paper extends our knowledge of comorbidity of substance use disorders (SUDs) and other psychiatric disorders by examining comorbidity of specific types of SUDs and risk of comorbidity separately for abuse and dependence. The research question is whether there is specificity of risk for comorbidity for different SUDs and whether greater comorbidity is associated with dependence. Data are presented from a probability sample of 4175 youths aged 11-17 assessed with the NIMH DISC-IV and self-administered questionnaires. SUDs outcomes are alcohol, marijuana and other substances in past year. Mean number of other comorbid disorders ranged from 1.9 for marijuana abuse to 2.2 for other substance abuse and 1.9 for marijuana dependence to 2.8 for other substance dependence. None of the abuse SUDs does not increase risk of anxiety disorders, but dependence does. Both abuse and dependence increased risk of comorbid mood disorders. Similar results were observed for disruptive disorders. Patterns of comorbidity varied by substance, by abuse versus dependence, and by category of other psychiatric disorders. In general, there was greater association of comorbidity with other disorders for dependence versus abuse. Marijuana is somewhat less associated with other disorders than alcohol or other substances. The strongest association is for comorbid disruptive disorders, regardless of SUDs category. Having SUDs and comorbid other psychiatric disorders was associated with substantial functional impairment. Females with SUDs tended to have higher rates of comorbid disorders, as did older youths. There were no differences observed among ethnic groups. When comorbidity of SUDs with other disorders was examined, controlling for other non-SUDs disorders for each specific disorder examined, the greater odds for dependence versus abuse essentially disappeared for all disorders except disruptive disorders, suggesting larger number of comorbid non-SUDs in part account for the observed effects for dependence.     

Does substance abuse affect outcomes for trauma-focused treatment of combat-related PTSD?

Comorbidity of substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) among combat Veterans is common, which creates a need for special consideration of treatment options. Controversy regarding trauma-focused treatments for individuals with comorbid SUDs may cause barriers to treatment delivery. Cognitive processing therapy (CPT) is frequently recommended for treatment of PTSD, but little is known about whether substance use comorbidity affects the outcome. This study compared outcomes for Veterans with PTSD and a substance misuse pattern against Veterans with PTSD without a comorbid SUD, who participated in a six-week residential group CPT treatment program. Lack of significant differences between groups on outcomes for PTSD or depression, p?>?0.05, suggests that individuals with comorbid substance misuse have outcomes for PTSD and depression similar to those without substance use comorbidity. Trauma-focused treatments may not be as problematic in this population as many clinicians believe. Attrition and demographic differences between the groups were also explored.     

Husbands' SUD is associated with higher levels of co-occurring but not non-co-occurring psychiatric disorders among their wives

OBJECTIVE: Substance use among husbands has been shown to be associated with higher rates of substance use and of psychiatric symptoms among their wives. However, substance use disorders (SUD) and psychiatric disorders (as opposed to substance use or psychiatric symptoms) are rarely rigorously assessed among large samples of couples, so it is unclear whether SUD among husbands are associated with SUD among their wives, and whether the wives also display a higher prevalence of co-occurring or non-co-occurring psychiatric disorders. We compared the level of SUD, of co-occurring (with SUD) psychiatric disorders, and of non-co-occurring psychiatric diagnoses among the wives of males with SUDs vs among the wives of males without SUDs. We hypothesized that the presence of SUDs among males would be associated with a higher level of SUDs, of co-occurring psychiatric disorders, and of non-co-occurring psychiatric disorders in their wives. METHOD: The subjects in this study were the spouses of adult men with a lifetime history of an SUD (SUD+ husbands, N=342) vs those with no lifetime history of an SUD (SUD- husbands, N=350). These subjects were recruited for participation in a longitudinal project designed to elucidate the etiology of substance use disorders. RESULTS: Co-occurring SUDs were five times more common among the spouses of SUD+ husbands than among the spouses of SUD- husbands (10.2% vs 2.0%, chi-square=19.7, p=0.000). SUD/depressive disorder and SUD/anxiety disorder were both seven times more common among the spouses of SUD+ husbands than among the spouses of SUD- husbands (19.4% vs 4.7%, chi-square=45.8, p=0.000; 14.3% vs 2.0%, chi-square=34.5, p=0.000). In contrast, non-co-occurring depressive disorders and non-co-occurring anxiety disorders were not more common among the wives of the SUD+ husbands than among the SUD- husbands. CONCLUSIONS: These findings demonstrate that SUD and co-occurring psychiatric disorders (with SUD) are more common among the spouses of SUD+ husbands than among the spouses of SUD- husbands, but non-co-occurring ("pure") psychiatric disorders are not more common among the spouses of the SUD+ husbands.     

Community hospital admission from the emergency department by persons with substance use disorders

Persons with a substance use disorder (SUD) are less likely to be insured and may have limited access to appropriate care, thereby increasing their reliance on emergency departments (EDs). We investigated whether health conditions and insurance status are significant predictors of admission to a community hospital directly from an ED visit with an SUD diagnosis. We analyzed the 2008 Nationwide Emergency Department Sample of the Healthcare Cost and Utilization Project. Lack of health insurance was disproportionately likely in ED visits that carried an SUD diagnosis, whether alcohol- or drug-related. Using regression analysis, most SUD and non-SUD diagnostic categories and many procedure categories were significantly related to subsequent hospital admission. Controlling for clinical characteristics, SUD-related ED visits covered by public or private insurance had substantially higher odds of leading to hospital admission than did uninsured visits. Policies that broaden insurance coverage may improve access to inpatient care for persons with SUDs.     

The Adolescent Community Reinforcement Approach (A-CRA) as a Model Paradigm for the Management of Adolescents With Substance Use Disorders and Co-Occurring Psychiatric Disorders

ABSTRACT. Background: Integrated treatment for youth with substance use disorders (SUDs) and co-occurring psychiatric disorders is recommended; however, there are few studies that have evaluated integrated treatment approaches. Methods: This paper includes a brief review of cognitive-behavioral and family therapies, since they have been demonstrated to be effective treatments for the disorders that commonly co-occur with substance use. It also describes how an integrated treatment paradigm has been implemented using one Empirically Supported Treatment, the Adolescent Community Reinforcement Approach (A-CRA). Results: There is existing research that supports the use of several A-CRA procedures to treat substance use and commonly co-occurring psychiatric disorders. Conclusions: In the absence of further research, it is reasonable in the interim to train clinicians in treatments that incorporate components that have been found to be effective for both substance use and commonly co-occurring psychiatric disorders. These treatments can then be adapted as needed based on an individual youth's set of problems. Further research is needed to test treatments for various combinations of SUDs and psychiatric disorders (i.e., depression, trauma-related problems, conduct disorder/behavior problems, and attention-deficit/hyperactivity disorder [ADHD]).     

Trauma and Substance Misuse: Critical Considerations in Understanding the Maelstrom

Research has established that a relationship between trauma and substance use disorders (SUDs) exists. The nature of the relationship and its dimensions are not well understood. Nevertheless, it is important to consider either problem when the other is present. Given the spate of traumatic events occurring globally in recent years, it is critical for the planning group for the development of the “For Whom Is It Permitted, for Whom Is It Forbidden” museum exhibit to consider the complex relationship between trauma and SUDs and ways of representing it in the exhibit. This article briefly discusses what is posited and known about trauma and SUDs in relation to one another. Key points to consider in developing representations of the relationship between trauma and SUDs are raised.     

Substance use disorder trajectory classes: diachronic integration of onset age, severity, and course

Background

Substance use disorders (SUDs) may be characterized by onset age, severity, substance type, course, and outcomes. SUD phenotypes in the literature typically consider each of these features in isolation. Conceptual frameworks and data collection procedures for assessing SUD phenotypes are increasingly “diachronic” in approach, providing for characterizations “throughout time”. The recent availability of statistical procedures for the identification of latent classes offers the possibility of developing SUD phenotypes integrating these developmental features. This article illustrates the utilization of SAS-TRAJ mixture modeling to characterize variations in SUD symptom trajectories to define phenotypes.

Methods

The subjects were 332 adult males with SUDs. Their course of symptoms from early adolescence through middle adulthood was retrospectively determined. Symptom trajectories were defined by the number of DSM-IV SUD symptoms by year of age. SAS-TRAJ mixture models identified trajectory classes. Model development, evaluation, and selection using this approach are discussed.

Results

Among these men with SUDs, six trajectory classes were identified, including groups characterized by early-onset and severe SUD symptoms persisting into adulthood, an early-onset group similar in adolescence but improving in adulthood, and other groups with symptoms emerging later with varying degrees of severity and persistence. The SUD trajectory classes were significantly different on comorbid psychopathology, particularly childhood disruptive behavior disorders.

Conclusion

The results present a new method for the comprehensive depiction of heterogeneity in SUD symptoms. Future studies may determine the extent to which SUDs phenotypes based on the course of symptom development inform etiology, prevention and treatment research.     

The Relationship Between Early Maladaptive Schemas,Depression, and Generalized Anxiety among Adults Seeking Residential Treatment for Substance Use Disorders

Abstract

Previous research has shown that early maladaptive schemas (EMS) play an important role in substance use, depression, and anxiety. However, few studies have examined the role of EMS within the context of all three concurrently. The goal of this study was to determine the role of EMS in predicting symptoms of Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) among adults in residential treatment for substance dependence. We used pre-existing patient records of adults diagnosed with a substance use disorder from a residential substance use treatment facility (N = 122). The EMS domains of disconnection and rejection and impaired limits were associated with symptoms of MDD and the domain of impaired autonomy and performance was associated with symptoms of GAD, even after controlling for age, gender, years of education, alcohol use, drug use, and symptoms of MDD (when predicting GAD) and GAD (when predicting MDD). Findings suggest that EMS may play an important role in comorbid mental health problems among men and women in residential substance use treatment. Continued treatment outcome research is needed to examine whether modification of EMS results in improved mental health and substance use outcomes.