Early maladaptive schemas, self-esteem, and changes in depression and anxiety in young adults during residential substance abuse treatment
Table of Contents Chapter 1: Introduction to the Present Study 1 Chapter 2: Cognitive Theory and Early Maladaptive Schemas 3 Chapter 3: Early Maladaptive Schemas and Substance Abuse .11 Chapter 4: Schema-Based Therapy Models 14 Chapter 5: Cognitive Theory of Depression and Anxiety 17 Chapter 6: Dual Disorders 18 Chapter 7: Assessment of Depression and Anxiety with Substance Abusers 21 Chapter 8: Self-Esteem 26 Chapter 9: Methods 28 Participants 28 Materials 29 Procedure 31 Data Analysis 34 Chapter 10: Results 35 Chapter 11: Discussion 45 References 52 u
List of Tables Table I 36 Table II 37 Table III 38 Table IV 39 Table V 40 Table VI 41 Table VII 42 in
1 Chapter 1: Introduction to the Present Study The primary goal of this research was to examine the associations and interactions between depression, anxiety, self-esteem, and early maladaptive schemas in young adults' ages 18-25 admitted to a residential substance abuse treatment program. Specifically, changes in self-reported depression and anxiety scores were examined over the course of a 31 day residential substance abuse treatment program. Changes in depression and anxiety were viewed in terms of the character and severity of early maladaptive schemas and global self-esteem. This study was a pilot study, as no previous research to date has examined whether the severity of depressive and anxious symptoms is associated with higher levels of dysfunctional early maladaptive schemas and low self- esteem in young adults in residential treatment for substance abuse. Young (1999, p.9), defined "early maladaptive schema," as "broad, pervasive themes regarding oneself and one's relationship with others, developed during childhood and elaborated throughout one's lifetime, and dysfunctional to a significant degree." Despite there being well-established research on the etiology and treatment of substance use disorders in young adults, no research to date has investigated the early maladaptive schemas of young adults with substance use disorders. The correlation between anxious and depressive symptomatology with early maladaptive schemas and self-esteem has not been explored in any clinical or non-clinical population.
2 Brotchie, Meyer, Copello, Kidney, & Waller (2004) conducted the only known existing study of early maladaptive schemas in individuals with a substance use disorder. The study was conducted with adult substance abusers dependent on either alcohol or opiates, and a non-clinical comparison group. However, this study, described in detail below, had significant methodological limitations. These limitations included its narrow focus in terms of choice of substance abused, lack of assessment of comorbid psychiatric diagnoses, and not acknowledging what level of care the clinical population was receiving. People develop maladaptive coping styles to avoid the strong emotions provoked by the activation of early maladaptive schemas (Ball, 1998). Cognitive-behavioral theoretical models, techniques used in relapse prevention, and coping skill interventions share the rationale that faulty cognition is one of the core components of addictive behavior. According to Ball (2007), the activation of painful, dysfunctional early maladaptive schemas may be a factor associated with relapse in individuals with substance use disorders. Early maladaptive schemas are also associated with disorder- specific cognitions, many of which are likely to impede therapy (Brotchie et al., 2004). Based on previous findings with adults meeting criteria for a substance use disorder, it is hypothesized that young adults in treatment for substance dependence will have higher levels of dysfunctional early maladaptive schemas in comparison to a non-clinical
3 comparison group (Brotchie et al, 2004; Ball, 2007). The dual-focus schema therapy model posits that when early maladaptive schemas become activated in individuals with comorbid substance abuse and chronic Axis I or II psychiatric disorders, the relapse risk increases (Ball, 1998, 2003,-2007). Based on existing adult research, it is likely that the early maladaptive schemas most frequently endorsed by young adults with comorbid substance abuse and depressive or anxiety disorders will reflect unhealthier core beliefs. Specifically, this study hypothesizes that young adults with substance use disorders that have comorbid depressive or anxious symptomatology will have higher levels of dysfunctional early maladaptive schemas and lower self-esteem. This hypothesis is based on a review of past research, where adult substance abusers had more maladaptive schemas than adults in a non-clinical population (Brotchie et al., 2004; Ball, 2007). Additional research findings which lend credence to this hypothesis include the findings of McBride, Farvolden, and Swallow (2007), that negative mood inductions lead to dysfunctional schematic processing in depressed individuals, and Jung's (1994) research that found that self- esteem was lower in individuals in treatment for comorbid alcohol abuse and depression when compared to a non-clinical population. Based on the limited research in this specific area, it is theorized that the early maladaptive schemas most frequently endorsed
4 by young adults with comorbid depressive or anxiety disorders will reflect unhealthier core beliefs. Chapter 2: Cognitive Theory and Early Maladaptive Schemas Cognitive theory posits that beliefs and assumptions significantly influence interpretations, perceptions, emotions, and behaviors (Beck, Emery, & Greenberg, 1985). According to Young (1994), beliefs arise from underlying schemas. Compared with other types of cognition, Young & Lindemann (1992) proposed that schemas are more pervasive than automatic thoughts and underlying assumptions. According to James, Southam, and Blackburn (2004), early maladaptive schemas are similar to core beliefs, which they define as the cognitive or verbal representations of underlying schemas. Early maladaptive schemas are much more resistant to change than more shallow levels of cognition. Thus, the idea of surrendering these beliefs during the process of change is theorized to be very difficult (Young & Lindemann, 1992). Thoughts, feelings, and impulses associated with particular early maladaptive schemas are associated with particular behaviors and coping strategies (Ball & Young, 2000), and may lead to disruptive affect, self-defeating behavior, and significant harm (Young, 1992). Early maladaptive schemas are also influential in the development and maintenance of psychiatric symptoms such as anxiety and depression (Young, Klosko, & Weishaar, 2003; Wellburn, Coristine, Dagg, Pontefract, & Jordan, 2002). High levels of
5 dysfunctional schemas have been found to underlie Axis I psychiatric disorders and Axis II personality disorders (Young, 1994; Ball, 2007). Thus, one can theorize that certain early maladaptive schemas may underlie the etiology of substance use disorders. Young, Klosko, & Weishaar (2003) theorize that schemas arise from core emotional needs that were insufficiently met during childhood, and propose five core emotional needs which are universal. These emotional needs include secure attachment; autonomy, competence, and identity; the freedom to express needs and emotions; spontaneity and play; and realistic limits and self-control. Frustration versus gratification of these needs result from the interaction of a child's innate temperament and early life experiences (Young et al., 2003). According to Young et al. (2003), four types of early life experiences facilitate schema acquisition. The first is toxic frustration of needs that results from the child not receiving enough positive experiences, such as understanding, love, or stability. The second early life experience is traumatization or victimization. The third early life experience is when a child receives too much of a certain good experience that leads to them becoming overly indulged or coddled. Fourthly, selective internalization or identification of schemas that may result from the child selectively internalizing their parents' thoughts, feelings, experiences, or behavior is theorized to lead to schema acquisition.
6 As early maladaptive schemas are accessible verbally, creating awareness of them in therapy can lead to insight into the underlying core beliefs contributing to maladaptive behaviors. Support for schema-driven cognitive therapies in the treatment of a wide range of disorders is increasingly evident in the literature, and has been tailored to a wider range of disorders and treatment settings (Riso & McBride, 2007). Schema-based models of cognitive-behavioral therapy are useful in the treatment of substance use disorders, especially for relapse prevention (Young et al., 2003; Ball, 2007). Ball (1998) theorized that individuals are likely to develop maladaptive coping styles to avoid the strong emotions provoked by the activation of early maladaptive schemas. Young (1994) proposed that certain schemas or schema domains play a role in the development of certain Axis I and Axis II psychiatric disorders. However, in a review of the literature, no studies were found which examined whether different early maladaptive schemas are endorsed by individuals who only have a substance use disorder, versus those with both a substance use disorder and a comorbid psychiatric diagnosis (Young, 1999). Schmidt, Joiner, Young, and Telch (1995) conducted a higher-order factor analysis of the Young Schema Questionnaire with clinical and non-clinical populations. They administered the Young Schema Questionnaire to a student sample and to a group of individuals receiving outpatient psychiatric services. Factor analyses matched the
7 rationally derived primary early maladaptive schemas originally proposed by Young (1990, 1991). In the clinical population, subjugation, entitlement, and social isolation emerged as independent factors, which may indicate that they are more extreme schemas that are less likely to be pronounced in a non-clinical population. Validity analyses indicated that clusters of early maladaptive schemas representing disconnection and overconnection, which are associated with feeling dependent and defective, might represent a risk factor for depression. Validity analyses indicated that individuals who feel incompetent, inferior, or vulnerable have a greater likelihood of experiencing anxiety (Schmidt et al., 1995). Young's schema theory (1990), proposes that early maladaptive schemas develop during childhood through relationships with caregivers. Young's schema theory is consistent with other schema theories (Beck, 1967; Segal, 1988), in that all theories present schemas as both stable and enduring structures, which are at the core of self- concept. The main theoretical difference between Young's theory and other schema theories is that early maladaptive schemas are viewed as unconditional, versus a theory like Beck's (1967), which proposes that underlying beliefs are conditional. The implications of this theoretical difference, is that the unconditional nature of early maladaptive schemas causes them to be more frequently activated, while more
8 conditional underlying beliefs are only activated when certain situations or stressors are present (Schmidt et al., 1995). According to Young (1990), schemas serve as a mechanism for understanding and managing one's environment during childhood. Once developed, selective filtering takes place, whereby evidence that corroborates a certain schema leads to it being extended and elaborated on throughout one's life. In adulthood, existing early maladaptive schemas become maladaptive. They may lead to anxiety and depression when real situations are perceived maladaptively, resulting in activation and reinforcement of that particular schema. Early maladaptive schemas are highly resistant to change and self-perpetuating. Due to their unconditional nature, they prevent realistic cognitive processing of information when it is inconsistent schematically. Cognitively, schemas are maintained by emphasizing information confirming the schema while minimizing information inconsistent with it. Jeffrey Young developed two self-report inventories, the Young Schema Questionnaire-Long form and the Young Schema Questionnaire-Short form. These measures are designed to assess which specific early maladaptive schemas underlie certain behavioral and symptomatic presentations and categories of psychopathology (Young, 1999). Young, Klosko, and Weishaar (2003) elaborated on Young's original conceptualization of eighteen early maladaptive schemas, by identifying and grouping the
9 schemas assessed in the Young Schema Questionnaire into 5 specific categories, or "domains," reflecting the underlying "unmet emotional needs" represented by each. Each schema domain specifies which unmet developmental needs lead to specific distorted expectations and dysfunctional behaviors. The Young Schema Questionnaire is a psychometrically sound research and clinical assessment measure. Both forms of the Questionnaire have psychometric utility and validity, adequate test-retest reliability, and good internal consistency. There is good support for the measure's factor structure, broadly reflecting Young's descriptions. Both Young Schema Questionnaires have discriminant and convergent validity with measures of psychological distress, cognitive vulnerability for depression and personality disorder symptomatology, and self-esteem ratings (Schmidt et al., 1995; Lee, Taylor, & Dunn, 1999). Riso, Froman, Raouf, Gable, Maddux, Turini-Santorelli, Penna, Blandino, Jacobs, and Cherry (2006) conducted a study that examined the long-term stability of early maladaptive schemas in individuals receiving outpatient treatment for depression over a two and a half to five year long period. Early maladaptive schemas were assessed by the Young Schema Questionnaire-Long Form three times; at the beginning of the study, two and a half years later, and five years later. Study results indicated moderate to good levels of stability for early maladaptive schemas, even when severity of depressive
10 symptomatology and negative emotionality were controlled for. Moderate levels of discriminant validity were also apparent. When compared to existing literature on the psychometric properties of the Young Schema Questionnaire, Riso & colleagues (2006) found that the stability and discriminant validity of early maladaptive schemas were similar in stability and validity to personality disorder features. Young, Klosko, and Weishaar (2003), proposed the existence of eighteen early maladaptive schemas. These schemas make up five broad categories of unmet emotional needs they called "schema domains." The first domain, "disconnection and rejection," include unmet needs for secure and satisfying relationships. This domain includes four schemas. They are "abandonment/instability" (the perceived unreliability or instability of individuals for support and connection), "mistrust/abuse" (the expectation that others will hurt, humiliate, lie, cheat, manipulate, or take advantage of you), "emotional deprivation" (expecting that needs for emotional support will not be appropriately met by others), and "social isolation/alienation" (feeling isolated from others, essentially different from other people, and/or not part of a group or community). The second domain, "impaired autonomy and performance," describes schemas concerning expectations that interfere with an individual's ability to separate, function independently, or perform well. It includes schemas of "defectiveness/shame" (feeling defective, bad, unwanted, or inferior or invalid in important ways, or that you would be
11 unlovable to those who love you if you were exposed), "dependence/incompetence" (believing you won't be able to handle daily responsibilities, without help from others), "vulnerability to harm or illness" (fear of an imminent catastrophe), "enmeshment/underdeveloped self (high needs for closeness at the expense of autonomy or normal development), and "failure" (the belief of inevitable failure, or feeling inadequate achievement-wise). The third domain, "other-directness," describes excessively focusing on other's needs and feelings in order to gain approval or love, or maintain connectiveness. It includes schemas of "subjugation" (extreme surrendering of control to others as a result of feeling coerced, to avoid anger, retaliation, or abandonment by others), "self-sacrifice" (putting other's needs at the expense of your own needs excessively), and "approval- seeking/recognition-seeking" (overly emphasizing approval and recognition from others, or doing things to fit in, at the expense of developing a secure sense of oneself). The fourth schema domain, "overvigilance and inhibition," reflects schemas that lead to suppressing spontaneous feelings or impulses due to the mindset of needing to meet rigid, internalized standards concerning performance and ethical behavior. Schemas in this domain include "negativity/pessimism" (overly focusing on the negative), "emotional inhibition" (inhibiting your communication of emotions to avoid feeling shame, disapproval of others, or because one fears a loss of self-control), "unrelenting
12 standards/hypercriticalness" (striving to meet extremely high internalized standards of performance in order to avoid perceived criticism), and "punitiveness" (believing others should be harshly punished for their mistakes) (Young, Klosko, & Weishaar, 2003). The fifth domain, "impaired limits," represents schemas that reflect poor internal limits, responsibility towards other people, or lacking long-term goal orientation. It includes schemas of "entitlement/grandiosity" (feeling superior and entitled to special rights and privileges), and "insufficient self-control/self-discipline" (problems exercising self and impulse control and poor frustration tolerance). Chapter 3: Early Maladaptive Schemas and Substance Abuse Brotchie, Meyer, Copello, Kidney, and Waller (2004) theorize that substance abuse is a way of coping with a perceived pattern of perceived personal flaws, arising from early maladaptive schemas. They investigated the early maladaptive schemas of a clinical sample of adults who met criteria for either an alcohol abuse/dependence diagnosis or an opiate abuse/dependence diagnosis, and who were currently in substance abuse treatment. Data was also gathered from a non-clinical group of non-students. Because alcohol abusers were significantly older than opiate abusers, age served as a covariate. Statistical analyses were performed between groups using a MANCOVA and other post hoc analyses.
13 Brotchie and colleagues (2004) had several important findings. There were significant differences found between alcohol abusers, opiate abusers, both alcohol and opiate abusers, and the non-clinical comparison group on the mean scores of twelve early maladaptive schemas. All three clinical samples had more early maladaptive schemas than the non-clinical sample. However, reliable differences between clinical groups were found with three early maladaptive schemas. Combined alcohol/opiate abusers had high levels of emotional inhibition schemas, while the two alcohol abusing groups; both alcohol abusers and the combined alcohol/opiate abusers, had significantly higher levels of subjugation and vulnerability to harm schemas. Thus, alcohol abuse is construed as relating to greater cognitive pathology, as assessed by early maladaptive schemas, compared to opiate abuse on its own. The researchers elaborate on this data by theorizing that alcohol abusers have higher levels of early maladaptive schemas than opiate abusers. They posit that cognitive processing styles may differ based on which substance is abused. Opiates are used to prevent the initial awareness of negative core beliefs. Alcohol is used to decrease the negative affect after it has been experienced (Brotchie et al., 2004). Calvete, Estevez, Arroyabe, and Ruiz (2005) investigated the factor structure and relationship between early maladaptive schemas and symptoms of affective disorders using the Spanish version of the Young Schema Questionnaire-Short Form, and several
14 measures of depression, anxiety, anger, and automatic thoughts, in a population of undergraduate college students. Findings of this study were consistent with the content- specificity theory (Beck, Brown, Steer, Eidelson, & Riskind, 1987; Steer et al., 1994; Clark, Steer, Beck, and Snow, 1996), which is described in detail in Chapter 5 of this dissertation. Early maladaptive schemas of failure, defectiveness/shame, and self- sacrifice were all associated with depression. They suggest a negative self-concept, shame, and a relegation of one's own interests, according to the researchers. Early maladaptive schemas of subjugation, failure, and abandonment/instability were predictors of anxiety symptoms. In a French study using a translated version of the Young Schema Questionnaire, individuals with a diagnosis of alcohol dependence reported higher levels of almost all early maladaptive schemas, especially with those related to insufficient self-control, mistrust or abuse, self-sacrifice, and abandonment (Decouvelaere, Graziani, Gackiere- Eraldi, Rusinek, & Hautekeete, 2002). Ball and Cecero (2001) conducted a study assessing which early maladaptive schemas were most predominant in a population of patients receiving outpatient methadone maintenance treatment. All participants met DSM-IV criteria for opioid dependence on agonist medication, and met diagnostic criteria for comorbid antisocial, borderline, avoidant, or depressive personality disorders. Correlations between
15 personality disorder severity and specific early maladaptive schemas were conducted. Antisocial personality disorder severity was most highly associated with mistrust/abuse, vulnerability to harm, and emotional inhibition schemas. Borderline personality disorder severity was associated with abandonment/instability and mistrust/abuse schemas. Avoidant personality disorder severity most strongly related to the subjugation schema. Depressive personality disorder severity was most closely associated with schemas of mistrust/abuse, social isolation, defectiveness/shame, failure to achieve, and subjugation. Additionally, the Young Schema Questionnaire-Long Form was better able to differentiate between avoidant personality disorder and depressive personality disorder than the Structured Clinical Interview for DSM-IV Axis II (SCID-II; First, Spitzer, Gibbon, Williams, & Benjamin, 1994), the NEO Five Factor Inventory (NEO-FFI; Costa & McCrae, 1992), and the Brief Symptom Inventory (BSI; Derogatis, 1992). These findings lend credence to the diagnostic utility of the Young Schema Questionnaire in the differential diagnosis of personality disorders amongst substance dependent populations. Pinto-Gouveia, Castilho, Galhardo, and Cunha (2006) conducted a study comparing early maladaptive schemas of individuals diagnosed with social phobia, other anxiety disorders, and a non-clinical control group. Findings indicated a different schematic structure in socially phobic patients compared to those with other anxiety disorders and those in the non-clinical group. Those with social phobia had higher levels
16 of early maladaptive schemas of disconnection/rejection than those with other anxiety disorders or those in the non-clinical group. Regression analyses indicated that the early maladaptive schemas of mistrust/abuse, social undesirability/defectiveness, entitlement, emotional deprivation, and unrelenting standards and shame as most significantly contributing to the variance in anxiety in social situations and with fear of negative evaluation by others. Chapter 4: Schema-Based Therapy Models Jeffrey E. Young's theory of early maladaptive schemas and his schema-focused therapy model have advanced cognitive-behavioral theoretical and therapeutic models of treatment. By proposing that early maladaptive schemas may underlie and shape core beliefs and underlie certain behaviors or symptoms, schema-based cognitive-behavioral therapy techniques have been developed, advancing treatment for chronic psychological and personality pathology (Riso & McBride, 2007). Schema-based models have also been found useful in the treatment of major depressive disorder and depressive symptomatology (McBride, Farvolden, & Swallow, 2007), chronic anxiety disorders (Young et al., 2003), personality disorders both comorbid with substance dependence and without (Young et al., 2003; Ball & Young, 2000), eating disorders (Young et al., 2003; Waller, Kennerley, & Ohanian, 2007), and helpful for individuals with chronic interpersonal difficulties (Young et al., 2003).
17 Schema-focused CBT (Ball, 1998; Young, 1994) has been suggested as an alternative or secondary form of therapy for substance abusers, when a motivational enhancement plus CBT approach is unsuccessful (Brotchie et al., 2004). Schema Therapy Jeffrey Young (1990, 1999), developed "Schema Therapy" to tailor traditional cognitive-behavioral interventions to improve the treatment of patients with chronic psychological and characterological problems, who often had difficulty benefiting from traditional therapeutic interventions. Schema therapy emphasizes exploring the childhood origins of current psychological and interpersonal problems, and focuses on emotive and experiential techniques and on the therapist-patient relationship. Schema therapy can be used in both short-term and long-term treatment paradigms, and often is used in conjunction with other therapeutic modalities (Young et al., 2003). Compared to other cognitive and cognitive-behavioral therapy approaches, schema therapy puts a greater emphasis on the chronic and characterological aspects that underlie Axis I and Axis II psychiatric disorders. Cognitive techniques in schema therapy are similar to those in CBT, in that they are sequential and build upon each other. First, the goal is to help patients test the validity of a schema by looking at the evidence for and against the schema, similar to the technique of testing automatic thoughts in traditional cognitive therapy. However, there is a greater focus on both present and past experiences,
18 rather than the solely present-focused approach of traditional cognitive therapy (Young et al.,2003). Schema restructuring is the goal of the next portion of schema therapy. The second step of schema therapy is "reframing the evidence supporting the schema." The goal of this step is to discredit past and current evidence that the schema is based on, and reattribute it to other causes. There is a focus on examining evidence from childhood during this process. The next step is to look into the coping responses arising from each schema, and list the advantages and disadvantages of each. The therapist during this stage aims to emphasize that although these coping skills were adaptive during childhood, they are maladaptive in adulthood. The goal of this stage is for the client to realize that increased happiness may accompany the use of healthier coping skills. Next, individuals are taught to engage in a debate between their "schema side," and "healthy side," helping to build more evidence against the schema (Young et al., 2003). Next, schema flash cards are employed, which list healthy responses to specific schema triggers that have been identified in the cognitive and schema restructuring phase. The reasoning behind their use is that they provide individuals with a way to engage in continual rehearsals of rational, healthy responses when they notice their schemas being triggered in daily life. Individuals carry them around and read them whenever the relevant schema is triggered (Young et al., 2003).
19 Dual-focus schema therapy is particularly efficacious with substance abusers that have responded poorly to past treatment (Ball, 1998; Ball & Rounsaville, 2006; Ball & Young, 2000). This therapy model is based on research and clinical findings with individuals who have an Axis II personality disorder and a comorbid substance use disorder. In the dual-focus schema therapy model, substance use may be the direct behavioral expression of the activation of certain early maladaptive schemas, for those with a substance use disorder comorbid to personality pathology. For individuals with both diagnoses, substance use may be more likely to result either when a schema is triggered in the domain of impaired-limits, or when an other-directedness schema is triggered within a dysfunctional interpersonal relationship or in an interaction with a substance-abusing peer. Additionally, this model proposes that relapse risk increases when schema avoidance takes place, especially involving schemas in the domains of disconnection and rejection or impaired autonomy and performance. Schema avoidance is evident in behaviors common to those with addictions, such as addictive self-soothing, compulsive stimulation seeking, social withdrawal, and psychological withdrawal (Young, 1994; Young et al., 2003). When schema avoidant behaviors appear, relapse risk increases and schema avoidance may be a relapse trigger in itself (Ball, 2007).
20 Chapter 5: Cognitive Theory of Depression and Anxiety Cognitive theories of the relationship and differences between depression and anxiety have been prevalent in the literature. A well-established positive relationship has been established between anxious and depressive symptomatology in adults, adolescents, and children (Kumar, Steer, & Beck, 1993; Clark & Watson, 1991). Depression and anxiety are associated with specific thought contents, which are important for diagnostic, assessment, and treatment purposes. In depression, cognitions concerning personal loss and failure are predominant, and in anxiety, thoughts of threat and danger predominate (Beck et al., 1987; Beck, 1991; Clark, Steer, Beck, & Snow, 1996). The cognitive content-specificity hypothesis proposes that loss cognitions are highly correlated with depressive symptoms, and that threat cognitions are highly correlated with anxiety symptoms. This theory has the support of a significant amount of literature assessing a variety of populations. Several studies have found even greater content specificity in clinical versus non-clinical samples (Beck et al., 1987; Steer et al., 1994). However, Clark, Steer, Beck, and Snow (1996), conducted a study that controlled for the high correlation between measures of depression and anxiety. They found that when symptoms were less distressing, there was a lower likelihood of content specificity. The findings of this study supported the content-specificity hypothesis for both inpatient
21 and outpatient adult psychiatric patients. The hypothesis had the greatest relevance when symptom distress was high, with negative cognitions significantly more specific to anxious and depressive symptomatology. Frequency of negative automatic thoughts was the symptom that most strongly differentiated between a diagnosis of major depression and panic disorder, in a study conducted by Clark, Beck, and Beck (1994) with a large psychiatric outpatient population as the sample. This study included both self-report and clinician rating scales. Discriminant function analysis of symptoms dimensions indicated that negative self- perception, anhedonia, and dysphoria were hallmarks of depression, while panic symptoms, cognitions concerning threats, worry, and tension were the most predominant symptoms of anxiety. Chapter 6: Dual Disorders Multiple clinical and epidemiological research studies have indicated a high rate of comorbidity between substance use disorders and psychiatric disorders. Findings have indicated that several risk factors for psychiatric disorders are also risk factors for the development a substance use disorder (Mueser, Drake, & Wallach, 1998). The National Institute on Drug Abuse (1993), cited in Miller, Leukefeld, and Jefferson (1994), claimed that the most common psychiatric disorders comorbid with substance abuse include major depression, dysthymia, anxiety disorders including phobias, antisocial personality
22 disorder, and psychosexual dysfunction. Specifically, individuals with depression and certain anxiety disorders were found to have a significantly higher risk of developing a substance use disorder (Grant, Stinson, Hasin, Dawson, Chou, & Dufour, 2004). Furthermore, several studies assessing overall psychopathology in alcohol dependent individuals have indicated that the most common diagnostic impressions are those of either anxiety or depression, both of which range in severity, and may or may not be indicative of an independent mood disorder coexisting with alcoholism. Estimations of symptoms of anxiety and depression in those seeking treatment for alcohol abuse or dependence are between 30-70 %. Agitation and psychic anxiety are common symptoms of the substance withdrawal process (Liappas, Paparrigopoulos, Tzavellas, and Christodoulou, 2002; Kushner, Sher, and Beitman, 1990; Swendsen, Merikangas, Canino, Kessler, & Rubo-Stipec, 1998). There has been a significant amount of research providing evidence for the category of "dual diagnosis," as related to psychiatric disorders comorbid to substance use disorders. High rates of dual diagnosis have been found in studies with treatment samples from drug and alcohol treatment settings, inpatient and outpatient psychiatric settings, and in community samples; and both cross-sectional and longitudinal research designs have indicated further evidence for this conceptualization (Miller, Leukefeld, & Jefferson, 1994).