Working Therapeutically with Working Therapeutically with Persons with Antisocial Persons with Antisocial Personality Disorder and Personality Disorder and Comorbid Psychosis or Bipolar Comorbid Psychosis or Bipolar Disorder Disorder Kim T. Mueser Mueser, Ph.D. , Ph.D. Kim T. Center for Psychiatric Rehabilitation Center for Psychiatric Rehabilitation Boston University Boston University mueser@bu.edu mueser@bu.edu
Overview Overview � Characteristics of antisocial personality disorder Characteristics of antisocial personality disorder � (ASPD) in people with psychosis or bipolar disorder (ASPD) in people with psychosis or bipolar disorder (severe mental illness: SMI (severe mental illness: SMI � Treatment studies of SMI including people with ASPD Treatment studies of SMI including people with ASPD � � Effective therapeutic strategies Effective therapeutic strategies �
Demographic Correlates of Demographic Correlates of ASPD in SMI Population ASPD in SMI Population � Male gender Male gender � � Younger Younger � � Lower levels of education Lower levels of education � � Less likely to be married Less likely to be married �
Prevalence of ASPD in SMI Prevalence of ASPD in SMI Population Population � 20% in New Hampshire co 20% in New Hampshire co- -occurring substance use occurring substance use � disorder treatment study (N = 168) disorder treatment study (N = 168) � 21% in Connecticut co 21% in Connecticut co- -occurring substance use occurring substance use � disorder treatment study (N = 178) disorder treatment study (N = 178) � 21% in Boston 21% in Boston- -Los Angeles co Los Angeles co- -occurring substance use occurring substance use � disorder family treatment study (N = 103) disorder family treatment study (N = 103) � 7% in New Hampshire Hospital study of admissions for 7% in New Hampshire Hospital study of admissions for � treatment of acute symptom exacerbation (N = 293) treatment of acute symptom exacerbation (N = 293) � These estimates based on self These estimates based on self- -report, and are potential report, and are potential � underestimates of ASPD: Hodgins Hodgins estimates 40% of estimates 40% of underestimates of ASPD: schizophrenia have ASPD schizophrenia have ASPD
CD, ASPD, and Recent SUD in Clients with SMI CD, ASPD, and Recent SUD in Clients with SMI (N = 293) (N = 293) Source: Mueser et. al. (1999)
Substance Use Correlates of ASPD Among Substance Use Correlates of ASPD Among People with Co- -Occurring Disorders Occurring Disorders People with Co � Higher rates of drug abuse Higher rates of drug abuse � � Earlier age at onset Earlier age at onset � � More rapid progression to dependence More rapid progression to dependence � � More severe health, social, and legal More severe health, social, and legal � consequences of substance use consequences of substance use � Stronger history of family substance use Stronger history of family substance use � disorder disorder
Psychiatric and Psychosocial Correlates of Psychiatric and Psychosocial Correlates of ASPD in People with SMI ASPD in People with SMI � More severe symptoms: More severe symptoms: � – Psychosis Psychosis – Depression – Depression – � Greater impairment in daily living skills Greater impairment in daily living skills � � Greater functional impairment Greater functional impairment � � More hospitalizations More hospitalizations � � More stress and conflict in family relationships More stress and conflict in family relationships � � Poorer problem solving, more prone to Poorer problem solving, more prone to � interpersonal violence interpersonal violence
ASPD Status by Offense Type ASPD Status by Offense Type 0% 10% 20% 30% 40% 50% 60% Homicide Sex off. Assault *** Robbery *** Arson Burglary Weapons ** Theft Parole Drug Forgery Other off. Disorderly DUI ** Driving ** No CD/ASPD CD Only Adult ASPD Only Full ASPD
Basis of Therapeutic Strategies for Basis of Therapeutic Strategies for Working with ASPD and SMI Clients Working with ASPD and SMI Clients � Four treatment studies of SMI: Four treatment studies of SMI: � – 2 RCTs of Assertive Community Treatment vs. 2 RCTs of Assertive Community Treatment vs. – standard case management for co- -occurring SMI occurring SMI standard case management for co and substance use disorder (1 in New Hampshire, 1 and substance use disorder (1 in New Hampshire, 1 in Connecticut) in Connecticut) 1 RCT of family intervention for co- -occurring SMI occurring SMI – 1 RCT of family intervention for co – and substance use disorder (in Boston and Los and substance use disorder (in Boston and Los Angeles) Angeles) – 1 open clinical trial of Illness Management and 1 open clinical trial of Illness Management and – Recovery for SMI clients diverted from jail into Recovery for SMI clients diverted from jail into community treatment (Bronx, NY) community treatment (Bronx, NY)
Therapeutic Strategy #1: Therapeutic Strategy #1: Adopt an Empathic Stance Adopt an Empathic Stance � ASPD associated with more severe symptoms, ASPD associated with more severe symptoms, � including depression and anxiety (presumably including depression and anxiety (presumably greater trauma exposure) greater trauma exposure) � Greater functional impairment Greater functional impairment � � More impulse control and mood regulation More impulse control and mood regulation � problems, but not necessarily more superficial problems, but not necessarily more superficial or interpersonally exploitative or interpersonally exploitative � Empathy plays critical role in understanding, Empathy plays critical role in understanding, � developing goals, establishing working alliance developing goals, establishing working alliance
Therapeutic Strategy #2: Therapeutic Strategy #2: Assertive Outreach Assertive Outreach � Greater severity of problems points to need for Greater severity of problems points to need for � more intensive, community- -based services based services more intensive, community � Assertive Community Treatment (ACT) model Assertive Community Treatment (ACT) model � found beneficial for reducing high rates of found beneficial for reducing high rates of hospitalization and homeless hospitalization and homeless � ACT often used for forensic psychiatric ACT often used for forensic psychiatric � patients, especially in Europe patients, especially in Europe � Unclear role for ACT in co Unclear role for ACT in co- -occurring disorders occurring disorders �
ACT Program Characteristics ACT Program Characteristics � Low case manager to client ratio (1:10) � Services provided in clients ’ natural settings � 24-hour coverage � Shared caseloads among clinicians � Direct, not brokered services � Time unlimited services
Controlled ACT Research Controlled ACT Research 25 Studies
Integrated Treatment for Co- - Integrated Treatment for Co Occurring Disorders Occurring Disorders � Concurrent treatment of psychiatric and Concurrent treatment of psychiatric and � substance use disorders by same substance use disorders by same treatment providers treatment providers � Motivational enhancement strategies Motivational enhancement strategies � � Comprehensive assessment and Comprehensive assessment and � treatment treatment � Minimization of treatment Minimization of treatment- -related stress related stress � � Harm reduction philosophy Harm reduction philosophy � � Role of assertive outreach unclear Role of assertive outreach unclear �
Study of ACT Delivery of Integrated Study of ACT Delivery of Integrated Treatment for Co- -Occurring Disorders Occurring Disorders Treatment for Co � 198 clients with SMI (75% schizophrenia or 198 clients with SMI (75% schizophrenia or � schizoaffective) schizoaffective) � 2 sites in Connecticut: Hartford & Bridgeport 2 sites in Connecticut: Hartford & Bridgeport � � 3 year follow 3 year follow- -up period with assessments every up period with assessments every � 6 months 6 months � Randomized to ACT (N = 99) or standard case Randomized to ACT (N = 99) or standard case � management (SCM) (N = 99) management (SCM) (N = 99) � Everyone received integrated treatment for co Everyone received integrated treatment for co- - � occurring disorders occurring disorders
ASPD Status ASPD Status 21% 21% Full ASPD Full ASPD Adult ASPD Adult ASPD only only 52% 52% CD only CD only 18% 18% No CD/ASPD No CD/ASPD 8% 8%
Which approach was better at Which approach was better at decreasing substance use? decreasing substance use? Did ASPD interact with the beneficial Did ASPD interact with the beneficial effects of ACT vs. SCM on substance effects of ACT vs. SCM on substance use and criminal justice outcomes? use and criminal justice outcomes?
Substance Abuse Treatment Outcomes Substance Abuse Treatment Outcomes 8 7 Site 1 ACT Site 1 STD Site 2 ACT 6 SATS Mean Site 2 STD 5 4 3 2 1 0 6 12 18 24 30 36 Study Months Essock, Mueser, Drake et al. Psychiatr Serv. 2006
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