Everyday Life Consequences of Substance use in Adult Patients With a Substance use Disorder (SUD) and Co-occurring Attention Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD)

A Patient's Perspective

Linda M Kronenberg; Karin Slager-Visscher; Peter JJ Goossens; Wim van den Brink; Theo van Achterberg

Disclosures

BMC Psychiatry. 2014;14(264) 

In This Article

Discussion

With regard to the everyday life consequences of SUD with co-occurring ADHD or ASD, it can be concluded that the underlying mechanisms appear to differ for the groups (i.e., impulsivity vs. passivity) but that the everyday life consequences of having a dual disorder are similar: both groups get caught in a vicious circle of symptoms and substance use. The cycle is more or less the same for the two groups: a jumble of thoughts and emotions; increased symptoms (i.e., impulsiveness or passivity); decreased structure; increased substance use; and occurrence of even more jumbled thoughts and emotions (see Figure 1). For both groups of patients, the jumble of thoughts and emotions can lead directly to agitation and substance use, which initially ameliorates the symptoms but exacerbates them later: for the SUD + ADHD group, substance use typically leads to increased impulsiveness; for the SUD + ASD group, substance use typically leads to increased passivity. In the long run, SUD increases the ADHD or ASD symptoms and interferes with self-management.

Figure 1.

Vicious circle entailed by dual diagnosis of SUD with ADHD or ASD.

Both groups function better when there is sufficient structure. However, substance use destroys structure, and this lack of structure can lead to a vicious circle of increased substance use. The SUD + ADHD group of patients mainly lacks inhibition of impulsiveness and therefore has considerable difficulties focusing as well as maintaining structure. This created a situation of agitation and thereby increased substance use and heightened impulsivity, with a further loss of structure and increased substance abuse as an outcome. In contrast, the SUD + ASD group has problems with initiation, the management of daily responsibilities, and getting into and holding on to structure. The outcome is passivity and melancholia, which can lead to substance use as a form of coping (see Figure 1).

In their review, Kushner & Mueser[19] described four models explaining the high prevalence of comorbid substance use disorders and other psychiatric disorders; the common factor model, the secondary substance abuse model, the secondary psychopathology model, and the bidirectional model. The current study contains various examples of processes consistent with each of these models: impulsivity as a common vulnerability factor, substance abuse to reduce dysphoria or to facilitate social engagement, substance abuse leading to impulsive behavior or passivity, and - most of all - the presence of (bidirectional) vicious circles of increasing substance abuse and increasing psychopathology.

Dealing With Impaired Executive Functioning

A possible key to treatment of SUD with a co-occurring ADHD or ASD and thus breaking the vicious circle of symptoms and substance use is attention to their cognitive or so-called executive functioning (EF). The problems that are solved by EF are essential for adequate social functioning. EF is essential for adequate functioning in two main domains: inhibition and meta-cognition. Inhibition refers to the ability of the individual to inhibit motor, verbal, cognitive, and emotional activities. Meta-cognition refers to the individual's nonverbal working memory, verbal working memory, planning abilities, problem-solving abilities, and emotional self-regulation.[16]

For alcohol-dependent patients, research shows that almost all executive functions are impaired.[17–21] For the patients in our study and thus patients with a dual diagnosis of ADHD or ASD and a co-occurring SUD, an accumulation of EF impairments may thus be the case.

Barkley[16] recently found ADHD patients to have both impaired inhibition and impaired meta-cognitive functioning (i.e., both non-verbal and verbal working memory limitations). Not being able to concentrate or remember things for a longer period of time, patients with ADHD may move from task to task without re-engaging or finishing a task and thus leave a series of uncompleted tasks behind them. This is consistent with what we found in the present study for SUD + ADHD patients who reported being impulsive, problems focusing, trouble keeping focused, and difficulties maintaining structure in several areas of their lives. SUD may thus worsen the problems of patients with ADHD. This means an accumulation of EF impairments.

ASD is also associated with impairments of both inhibition and meta-cognition.[22,23] Patients with ASD have been shown to have problems with intention formation (i.e., performance planning), intention initiation (i.e., switching, time monitoring) and execution (i.e., task completion, switching, planning adherence, efficiency). Flexibility remains particularly impaired across ages in ASD, whereas working memory, initiation, and organization become increasingly problematic over time. SUD may thus worsen the problems for patients. This means an accumulation of EF impairments. This pattern of findings is consistent with what we detected in the present study for the SUD + ASD patients who reported being passive, difficulties with structure, and problems organizing various areas of their lives.

Clinical Implications

The results of this qualitative, interview study show how SUD creates a vicious circle of symptoms and substance use in patients with a dual diagnosis of SUD and ADHD or ASD. We also gained insight with this information into what clinicians can do to break the vicious circle of symptoms and substance use: SUD + ADHD patients should be helped to refrain from action and SUD + ASD patients should be helped to take action. Patients should be helped to create and maintain structure in their lives, and their self-management skills need to be strengthened to do this. In addition, SUD + ASD patients may initially be offered controlled substance use in the absence of appropriate behavioural alternatives for the realization of a treatment goal. A patient with SUD + ASD, for example, may be helped to engage in social activities with reduced drinking (i.e., controlled substance use) and thus to master the behavioural repertoire needed to participate in social activities.[24]

Clinicians should nevertheless realize that reduced substance use or total abstinence will not always result in better planning, greater structure, or increased initiative. The cognitive impairments arising from SUD add to the often chronic, cognitive impairments associated with ADHD and ASD, which means that reductions in substance use may help but are not very likely to fully restore the cognitive functioning of individual with a dual diagnosis of SUD and ADHD or ASD. The goal of the treatment and care for these patients should thus be maximization of their long-term welfare — however the patient defines this — by helping them to break the vicious circle of symptoms and substance use. Support, reinforcement of available skills, and viable alternatives for cognitive impairments should always thus be considered.

Strengths and Limitations of the Present Study

The conduct of the interviews in the present study by two independent researchers increases credibility and reliability.[25] Analysis of the data was performed by the two researchers independently and final coding was based on consensus between the two researchers. Data saturation was reached when coding the statements selected from the transcripts for discussion topic, main themes, and relevant points, which indicates the validity of the study.[26]

The group of responders and non-responders were comparable with regard to the intensity of care, which suggests that our patient population was representative. A limitation of the study was that the researchers did not use cross-over blind coding, which would have added to the reliability. Other possible limitations were that the SUD + ASD group included only males and that co-occurring mental health conditions aside from ADHD and SUD or ASD and SUD were not assessed.

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