4.2.1. Individual approaches

dysfunction. Severe symptoms are likely to result in patient stigmatization of self and loved ones, inadequate clinical care and rehabilitation, and the stigma of shame and family burden. Many family members hide their relationships or consider the illness to be a source of stigma when a relative suffers from PDD. Those in contact with dual-diagnosis persons may also experience distress, tension, and conflict within these relationships. Interpersonal conflicts are often associ-

Rates of treatment noncompliance may decrease, reducing motivation for change and making engagement more difficult. Persons may drop out of long-term programs, retard progress, and

Professional nurses have observed that PDDs have a low tolerance for stressors and a narrow repertoire of coping skills, some of them unhelpful even in the short term. These PDDs frequently develop idiosyncratic avoidance methods to manage positive symptoms such as delusions and hallucinations. These methods may become habitual and generalized. Research

Antipsychotics are a standard treatment for PDD, effectively managing symptoms. Case studies demonstrate that the antidepressant olanzapine may reduce psychotic symptoms induced by drug addiction. Dopamine antagonists have also demonstrated effectiveness in decreasing drug addiction. Research has shown that psychotic symptoms are associated with changes in brain chemistry. Antipsychotic medications restore the brain's natural chemical balance, reducing or eliminating psychotic symptoms. Medications may require weeks to work. Conventional antipsychotics are dopamine antagonists and target one of five subtypes of dopamine receptors in the brain. Dopamine 2 (D2) receptor antagonism in the mesolimbic tract improves hallucinations and delusions, but the conventional antipsychotic blockade of all D2 receptors causes other problems. Antagonizing D2 receptors in the mesocortical dopamine pathway worsens negative symptoms including avolition, anhedonia, alogia, and affective flattening. Atypical antipsychotics antagonize serotonin 5HT2A receptors as well as D2 antagonism seen with conventional antipsychotics. Serotonin affects dopamine differently in each of the four pathways. In the nigrostriatal pathway, serotonin antagonism increases dopamine release, resulting in fewer reports of movement disorders. Serotonin antagonism in the tuberoinfundibular pathway eliminates serotonin's ability to increase prolactin levels, mitigating the effect of two blockades in this pathway. In the mesocortical pathway, where serotonin 2A receptors predominate, antagonizing serotonin increases dopamine. This is thought to be responsible for improved cognition, affection, and motivation seen with antipsychotics. Weak serotonin 2A antagonism in the

destabilize illnesses, contributing to psychosocial instability [16, 19].

ated with dual diagnoses [3, 15, 17, 18].

52 Drug Addiction

3.4. Impact upon treatment adherence

4. Treatment modalities of PDD

4.1. Pharmacotherapy

has suggested the following treatment modalities:
