Transcript The Changing Face of Women`s Addiction

THE CHANGING FACE OF
WOMEN’S ADDICTION
Penelope P. Ziegler, M.D.
Medical Director
Florida Professionals Resource Network
Demographics: Gender Differences
• Alcoholism
• Lifetime prevalence
Men: 17%
women: 8%
Incidence in women has been increasing over past 30 years
• Currently 4-5 million female alcoholics
• Prevalence of other substance abuse and dependence
• Current illicit drug use
Men 9.9
Women 6.3
Less specific data on dependence, abuse
• Men > women with non-pharmacologic drugs
• Women > men with prescription drugs
Prevalence
10
9
8
7
6
5
4
3
2
1
0
Alcohol
St. Drugs
Rx Drugs
F 18-30 M 18-29 F 30-44 M 30-44
How Are Women’s Addictions Different?
• Physiological Differences
• Psychological Differences
• Social Differences
• Different Treatment Needs
Physiological Differences
• Metabolism of alcohol
• Gastric alcohol dehydrogenase
• Body fat distribution
• Hormonal influences
• Tolerance
• Body size
• ? Social expectations
• “Telescoping”
• Later onset of heavy use
• More rapid progression with earlier onset of severe physical
and psychological complications
Psychological Differences
• Different defense mechanisms
• Self-blaming vs. blaming others
• Somatizing
• Different denial styles
• Internalizing vs. externalizing
• Rationalizing
• Different identity components
• Caretaker
• Selfless
Social Differences
• Alcohol
• Double standard persists
• Special stigma attached to mothers
• Fetal alcohol spectrum disorders
• Assumption of neglect and/or abuse
• Longstanding association of alcohol and other drug abuse
with sexual promiscuity
• Intoxicated women are considered “fair game”
• Stereotype which may become a self-fulfilling prophecy as
addiction progresses
• Impact on mother-child relationship
Social Differences (Cont.)
• Prescription drugs
• Opioids
• Sedatives
• Benzodiazepines
• Barbiturates
• “Z” drugs (zolpidem et al)
• Carisoprodol (Soma)-> meprobamate
• Stimulants
• Amphetamines and other ADHD medications
• Phentermine and other appetite suppressants
• The physician as enabler
Social Differences (Cont.)
• Tobacco
• Women are less likely to smoke than men, although social stigma is
less than in past
• Much less likely to use smokeless tobacco
• Once they start, women have less success in quitting smoking
• Medications definitely beneficial
• Non-chemical addictions
• Compulsive shopping, spending
• Gambling
• Sex addiction vs. relationship addiction
Social Differences (Cont.)
• Illicit Drugs
• Women today are involved in whole range of illegal drug use, abuse
and distribution
• More likely to trade sexual favors for drugs
• Violence
• Women using illicit drugs are exposed to variety of physical violence
• Sexual violence common, often causes PTSD
• Domestic partner assault common
Co-Occurrence of Addiction and Sexual Trauma
• Studies in women seeking treatment for sequelae
of sexual trauma
• 40-80% meet diagnostic criteria for substance use disorder
(abuse or dependence)
• Many began using drugs to medicate symptoms
• Studies in women entering addiction treatment
• 50-80% have positive history for sexual abuse
• Many have never disclosed trauma prior to treatment
• Commonly PTSD symptoms emerge or worsen as woman
completes detoxification
Relationship of Women’s Addiction and
Sexual Trauma
• Childhood sexual trauma
• Incidence of severe psychopathology depends on three factors
• Secrecy and shame
• Blame and threats
• Persistence of negative world view
• Children of addicted families at highest risk
• Adult sexual trauma
• Higher incidence of PTSD than other severe traumas such as
combat, terrorism
• Immediate counseling lowers incidence
• Beta blockers may also help in acute aftermath
• Self-medication with alcohol, other drugs common
Inpatient Detoxification Treatment Study
N=101
Hien and Scheier, 1996
70
60
50
40
30
20
10
0
Partner
Violence
Rape
Stranger
Assault
ever
Harder to Get Women Into Treatment
• Very real social issues
• Lack of resources
• No money
• No insurance coverage
• No programs for women with children, pregnant women
• Lack of family support
• Lack of employer support
• Very real psychological issues
• Denial strategies (defenses) are shame-based
• Consequences are frequently more internal than external,
reinforcing minimization and rationalization
Shame Delays, Complicates Diagnosis
• Women unable to reach out for help
• Using in isolation
• Acting “as if” everything is okay
• Hiding truth of progressing addiction
• If help is sought, she appears to be (and may be) depressed, anxious,
physically ill
• Family, medical professionals miss reality of addiction diagnosis, enable
continued use
• Does not fit stereotype of alcoholic, addict
• Still practicing her profession
• Too clean, upstanding, well-educated, stylishly dressed
• Still involved with her children
Intimate Partner Violence
• Another shame-based secret
• Professional women no less likely to be battered
than non-professional women
• Professional women even less likely to seek help
when being battered
• Usual reasons of fear, intimidation
• Additional shame due to conflict between professional
image and reality of her perceived helplessness in her
domestic relationship
Harder to Keep Women in Treatment
• External pressures
• Partner and children demanding more attention, time at home
• Job is in jeopardy
• May be no insurance coverage, or family unable to survive
without her income
• Internal pressures
• Shame and fear of others’ judgment
• Worries about welfare of family
• Fears about “paybacks”
Core Treatment Issues for Women
• Assessment
• Most standardized screening tools designed for men, focus
on behavioral consequences
• Women respond best to unstructured, open-ended interviews
focusing on emotional consequences
• NIDA-modified ASSIST better than most
• Choosing a treatment program
•
•
•
•
Recognizes special needs of women
Has gender-specific groups
Addresses co-occurring disorders
Addresses re-entry issues
 Returning to work
 Returning to family, relationship
Other Issues in Primary Treatment
• Health concerns
• Referral for GYN and mammography services if needed
• Nutritional education and planning
• Chronic pain
• Co-morbid psychiatric disorders
•
•
•
•
Post-traumatic stress disorder
Affective disorders
Other anxiety disorders
Eating disorders
• Recovery environment
• Alcohol and drug free residence or alternative safe living arrangement
• Supportive primary relationship
• Plans for return to work, recovery support and continuing care in place
prior to completion of primary treatment
Therapeutic Interventions
• Group therapy
• Women’s group
• Mixed group
• Individual therapy
• CBT
• DBT
• Insight-oriented
• Adjunctive therapies
•
•
•
•
Expressive nonverbal therapies (art, movement, music, etc.)
EMDR
Biofeedback, neurofeedback
Acupuncture
• Pharmacotherapy
Special Issues for Women of Color and
Other Cultural and Ethnic Minorities
• Dealing with the legacy of racism in women’s
self-esteem, assertiveness
• Dealing with the overt and covert racism/ cultural bias
• In treatment programs and providers
• In peers
• Dealing with society’s racist and ethnic prejudices as
they affect women with addiction
• Dealing with sexism within one’s own race or ethnicity
Special Issues for Lesbians, Bisexual
Women and Gender Minorities
• External Factors contributing to chemical use
• Settings for socialization and meeting other women
• Women’s bars, “gay” bars
• Sports activities- usually sponsored by bars, breweries
• Common sexual practices
• Use of sedative drugs for relaxation
• Use of stimulants to increase libido, arousal
• Unsupervised use of hormones
• Internal Factors contributing to chemical use
• Self-medication of unresolved internalized self-rejection:
homophobia/ heterosexism/ rigid gender expectations
• Self-medicating symptoms of PTSD which may be exacerbated by
homophobic/ heterosexist/ binary experiences in treatment
Co-Occurring Psychiatric Disorders
• Affective disorders
•
•
•
•
Major depression
Depressive disorder, NOS
Dysthymic disorder
Bipolar disorder
• Anxiety disorders
• Panic, with or without agoraphobia
• Post traumatic stress disorder
• Eating disorders
• Bulemia nervosa
• Anorexia nervosa
• Eating disorder, NOS
• Personality disorders
Body Image Issues
• Our culture creates unattainable ideals for
women’s bodies
• Thinness
• Perpetual youth
• Sexual trauma creates shame-based identity due to
violation of self through an attack on the body
• Addiction further distorts body image and adds more
shame via behavior associated with getting and using
alcohol and other drugs or while under the influence
• High incidence of eating disorders among addicted women
Is the Home a Safe Place?
• Is the home chemical free?
• Spouse or partner
• Children
• Parents
• Is the woman safe from physical and sexual abuse?
• Very high incidence of domestic violence in couples where woman has
a substance use disorder
• Does not just stop when she gets sober
Twelve-Step Programs and Women
• Some barriers frequently encountered
• The Program literature
• Sexist, heterosexist and homophobic attitudes of members
• Meeting choices
•
•
•
•
Women’s meetings
GL meetings for lesbians
Closed vs open meetings
Speaker meetings vs discussion meetings
• Relationships in recovery
• The “13th Step”
• Too much too soon
• Too little too late
Preparing Women for Successful
Twelve Step Program Participation
• Outdated, sexist language and ideas
• Many readings and prayers are taken from “treasured” literature
written in the 1930’s and ’40’s
• Do not reflect attitudes of most women in AA and NA today
• Some Christian prayers used by tradition, but participation not required
• Principles vs. Personalities
• AA and NA have no opinion on “outside Issues” (Tradition 10)
• Medications
• Sexual orientation
• Women’s rights, feminism, etc.
• Members of these organizations do have strong opinions and may try
to influence newcomers
• Reinforce importance of avoiding new intimate relationships
Questions?