8. Dual diagnosis and facilitating change Flashcards
What are other terms for Dual diagnosis?
co-morbidity / co-occurrence
What is dual diagnosis?
when there is more than one diagnosis. i.e. 2 or more health problems (e.g. Medical, Mental health, Alcohol and Drug, Intellectual Impairment, etc)
What are the distinctions of dual diagnosis?
o Heterotypic / Homotypic
o Concurrent / Successive
What is an example of the Heterotypic / Homotypic distinction of dual diagnosis?
E.g. mental health and physical disorder vs 2 mental health disorders
What is an example of the concurrent / successive distinction of dual diagnosis?
E.g. alcohol dependence and depression at same time vs panic disorder in teenage years and cannabis abuse in twenties
What did Rita Mae Brown suggest that the statistics on sanity are?
“The statistics on sanity are that one out of every four Americans is suffering from some form of mental illness. Think of your three best friends. If they’re okay, then it’s you.”
What percentage of the population will experience a mental health disorder in their lifetime?
20-30% of the population
Over 12 months, what percentage of the population will experience a mental health disorder?
18%
What percentage of the population, over 12 months, will experience anxiety, substance use and affective?
10% anxiety, 8% substance use, 6% affective (NSMHW, 1997)
If you have a mental health disorder what are you likely to have?
substance use issues and vice versa
What is the likelihood that if you have a mental health disorder that you will substance use issues?
There is considerable variation to this answer. Dual diagnosis prevalence estimates a range from 30-90%
Why does the likelihood that having a mental health disorder will lead to substance use issues vary?
- Depends on diagnostic criteria (Severe, Axis I/II, PD, Sub-clinical)
- Setting (e.g. A&D vs MH, treatment vs community)
- Specific groups (e.g. Indigenous, homeless)
- Gender also a factor
In the past year, what is the prevalence (%) of substance use in Australian males?
8.3%
In the past year, what is the prevalence (%) of substance use and anxiety in Australian males?
1.4%
In the past year, what is the prevalence (%) of substance use and affective in Australian males?
0.6%
In the past year, what is the prevalence (%) of substance use, anxiety and affective in Australian males?
0.8%
In the past year, what is the prevalence (%) of anxiety in Australian males?
3.6%
In the past year, what is the prevalence (%) of anxiety and affective in Australian males?
1.3%
In the past year, what is the prevalence (%) of affective in Australian males?
1.4%
In the past year, what is the prevalence (%) of affective in Australian females?
3.6%
In the past year, what is the prevalence (%) of anxiety in Australian females?
7.3%
In the past year, what is the prevalence (%) of anxiety and affective in Australian females?
3.1%
In the past year, what is the prevalence (%) of anxiety and substance use in Australian females?
0.9%
In the past year, what is the prevalence (%) of anxiety, affective and substance use in Australian females?
0.8%
In the past year, what is the prevalence (%) of substance use and affective in Australian females?
0.3%
In the past year, what is the prevalence (%) of substance use in Australian females?
2.4%
what are the most common mental illnesses in alcohol and drug settings?
o Mostly anxiety, depression, and personality disorders
o Some psychosis/schizophrenia
what are the most common drugs in the mental health settings?
o Mostly alcohol and tobacco
o Some cannabis/speed/heroin
what percentage of nicotine use is in those with psychosis?
67%
In causal hypothesis depression, what are the general depressant effects of alcohol?
- Interferes with medications
* Long term effect on relationships, employment, health, etc…
In causal hypothesis depression, what are the general depressant effects of cannabis?
- Long-term use may cause ‘depression-like’ symptoms
* Hypothesised ‘Amotivational syndrome’
In causal hypothesis depression, what are the general depressant effects of opiates?
• Lifestyle related factors associated with opiate dependence
In causal hypothesis depression, what are the general depressant effects of stimulants?
o Existing depression may get worse when coming down
o Common in the months following cessation
o Use/abuse may worsen the sleep / wake cycle
in causal hypothesis anxiety, what are the common features of withdrawal from drugs?
agitation, anxiety and irritability
In causal hypothesis anxiety, what are the effects of alcohol?
Alcohol related problems can create new worries
In causal hypothesis anxiety, what are the effects of cannabis?
Paranoia a common symptom of intoxication
In causal hypothesis anxiety, what are the effects of stimulants?
- chronic use - anxiety states and panic
* high doses - obsessive cognitions and compulsive behaviours
what does the causal dopamine hypothesis lead to?
psychosis
in the causal hypothesis psychosis, what are the effects of cannabis?
o Hypothesised to precipitate psychotic episodes
o Some evidence suggests a causal link, but still debated in literature
o Pharmacology and potency (THC vs CBD; Dose-response)
o Cannabis use known to increase rates of hospitalisation, psychotic relapse and psychotic symptoms
o Synthetic Cannabis a largely unknown area, but anecdotal reports are concerning
in the causal hypothesis psychosis, what are the effects of stimulants?
may directly cause psychotic episodes
what is the cause of amphetamine on psychosis?
brief psychotic reaction that may last for several weeks
What question does amphetamine psychosis raise?
can this trigger a more chronic psychosis?
In the causal hypothesis psychosis, what are the effects of alcohol?
o Negative symptoms worse and affects treatment
o Non-compliance with medication and higher relapse rates
What is the effect of drugs related to dopamine on psychosis?
reinforcing
what happens to the mental state when poly-drug use occurs (i.e. when a cocktail of drugs are used)?
o Uppers and downers cycle
o Possibly Simulates Bipolar Affective Disorder
In causal hypothesis mental health leading to alcohol and drug disorders, what is social lubricant?
Depressant drugs used as a form of “self-medication” of anxiety sumptoms
In causal hypothesis mental health leading to alcohol and drug disorders, what is “pick me up”?
Stimulant drugs used as self-medication of depression
In causal hypothesis mental health leading to alcohol and drug disorders, what are pain relieving drugs (e.g. opiates) used for?
used to manage chronic emotional pain/trauma
In causal hypothesis mental health leading to alcohol and drug disorders, what is “drowning your sorrows”?
using pain relieving drugs to manage chronic emotional pain/trauma
In causal hypothesis mental health leading to alcohol and drug disorders, what are opiates and sedatives commonly linked to?
a history of trauma (up to 90%)
In causal hypothesis mental health leading to alcohol and drug disorders, what is cannabis used for?
to manage issues with low appetite
In causal hypothesis mental health leading to alcohol and drug disorders, what are stimulants used for?
to supress appetite
In dual diagnosis, what are the issues for the client?
- Greater severity of Disorders
- Loss of support networks/extra challenges
- Poorer self care
In dual diagnosis, what does the issue of greater severity of disorders cause the client?
o More hallucinations, depressive symptoms and suicidal ideation
o Relapse risk increased
o Rehospitalisation
o Effects on medications
In dual diagnosis, what does the issue of loss of support networks/extra challenges cause the client?
o Unstable accommodation, criminal justice system o Family / relationship issues / stress o Double stigmatisation o Harder to receive/access service o Lack of education o Forensic mental health/legal issues
In dual diagnosis, what does the issue of poorer self care cause the client?
Increased risk taking behaviour (esp. HIV)
what can dual diagnosis of mental health lead to
stigmatisation and having less opportunities in life
in dual diagnosis, what are the issues for treatment services?
- Complex presentations
- Diagnoses are often unclear
- Lack of dual expertise or awareness of issues
- Added work vs more effective work perceptions
- Lack of flexibility in service provision
- Confronts clinicians own issues?
In dual diagnosis, what is involved in the issue of complex presentation for treatment services?
o More than one drug use/mental health issue
o Psycho-social issues
In dual diagnosis, what is involved in the issue of unclear diagnosis for treatment services?
o Lack of screening
o Misdiagnosis
In dual diagnosis, what is involved in the issue of lack of dual expertise or awareness for treatment services?
Lack of confidence in DD
In dual diagnosis, what is involved in the issue of lack of flexibility in service provision for treatment services?
o Appointment based models
what are positive symptoms of schizophrenia?
- Hallucinations
- Delusional thinking
- Disorganised speech
What are negative symptoms of schizophrenia?
- Flattened affect
- Lack of motivation
- Poverty of speech
what are symptoms for depression?
o Low mood or irritable o Loss of interest in things o Appetite issues/weight variations o Sleep problems o Reduced activity o Lack of energy o Guilt/worthlessness o Poor concentration o Suicidal ideation
What does use of substances cause or exacerbate?
an underlying mental health problem (Primarily Substance Abuse)
What can mental health disorders lead to?
substance use and abuse (Primarily Mental Health, e.g. Self-medication)
what is the relationship between mental health disorders and substance use disorders?
they can develop together and reinforce each other (Bi-directional Model, e.g. Benzodiazepines and Depression)
how are mental health and substance use disorders developed independently of each other?
due to common causes or risk factors (Common Factors, e.g. Trauma/Adversity/etc…)
regardless of the relationship between substance use and mental health disorders, what eventually can occur>
usually become inter-connected over time and result in a worsening clinical picture
what are research provides not clear on with regards to dual diagnosis?
there is no clear answer on causal relationship between substance use disorders and mental health disorders as a causal link has been demonstrated in both directions
regardless of whether there is a causal relationship between mental health disorders and substance use disorders, what will neither assist in?
neither will assist in the recovery from, treatment of, or relapse prevention of the other
What is the best way to manage dual diagnosis?
The best way to manage is not dependent on the cause, rather it requires concurrent treatment and management
what are the two treatment models?
Alcohol and drug services and mental health services
how are treatment models characterised?
sequential and parallel
what is the third specialist service in the treatment model?
dual diagnosis services
what does it mean when services are collaborative?
they are linked and have some overlap
what does it mean when services are integrated
alcohol and drug services are within the mental health services
What has changed in the last 20 years with regards to national and state programs?
we have seen more focus on need to respond to DD. Particularly in Victoria
what has national and state funding provided with dual diagnosis?
provide guidelines and support, and some specific services for DD. E.g. Headspace, dual diagnosis specialist positions
What are some issues with the variation between states with their approach to DD?
- Need for greater alignment with what is working?
* Response within mental health systems the priority?
When is evidence based treatment more effective?
o Integrated o Focused on maintaining motivation & promoting treatment engagement o Assertive case management o Extends over several months o Based on “no wrong door” approach
How big is the evidence base for DD?
limited but increasing
what is majority of research for DD on?
pharmacological management
What makes the results for research on DD promising?
SSRIs supported in most cases
• Initial activation issues
• 2-6 weeks until effective
• less effective when alcohol misuse present
what is the main problem of DD?
the rule rather than the exception in treatment
what are the issues that exist that make DD worse?
Assessment difficulties, service variations, attitudes, perceptions, stigma, lack of expertise and training, poor outcomes, loss of social connection, legal issues
What does solving the problem of DD require?
coordinated, educated, integrated workforce that treats the problems with understanding and support
What is the old way of helping people change?
- Confront “addictive personalities”/denial
- Key Skill - Coercion
- Resistance, argument, reduced change
What is the new way of helping people change?
motivational interviewing
what are the 5 important assumptions of motivational interviewing?
- Motivation is a state not a trait
- Resistance is not a force we must overcome
- Ambivalence is normal
- Person seeking help should be an ally rather than an adversary
- Recovery and change are innate, constant and intrinsic to the human experience
what is central to addictive behaviours?
ambivalence
how does overcoming ambivalence help with addictive behaviours?
o Awareness of risks, costs & harms
o Also attached and attracted to behaviour
how does confrontation not help addictive behaviours?
confrontation about adverse consequences causes arguments and often reinfoces reasons for continuing
What is ambivalence?
coexisting & conflicting feelings about behaviour which is normal, understandable, acceptable, and expected
Why is ambivalence such an issue?
Strong & sometimes long held attachment to problem behaviour (e.g. physical dependence, social association, conditioned association, help with coping, etc…)
How is the change model structured?
process rather than an event
What is the change model a process of?
Process of changing addictive behaviours happens via a series of stages from pre-contemplation to maintenance
what is the process of the change model?
contemplation, preparation, action, maintenance, relapse
when stage of the change model does termination of addictive behaviours occur?
maintenance
when stage of the change model does precontemplation of addictive behaviours occur?
contemplation
What occurs in pre-contemplation?
the user is a happy user and is not planning to change the foreseeable future
How do users in the pre-contemplation stage see their behaviour?
uninformed or underinformed. “It isn’t that they can’t see the solution. It is that they can’t see the problem.”
What is a person in the precontemplation stage’s approach to change?
- Resistant to change
* Sometimes demoralised following relapse
what occurs in the contemplation stage?
the user is on the fence
• Aware of problem
• Seriously thinking about/considering change
• Not yet made commitment to change
• Ambivalence - Weighing up the pros and cons
what occurs in the preparation stage?
making a plan for change
• Plan for action in next month
• Open to information and support
• May have made small changes - e.g. Reduced smoking slightly
what occurs in the maintenance phase?
making changes that last
• Changes maintained for 6 months or longer
• Focus is on preventing relapse
• More confident
What occurs in the relapse stage?
- Rule rather than exception- Most people don’t make it on first attempt
- Can go back to any stage
- Can happen on multiple occasions
- Does not mean that the person is unmotivated
what is the prevalence of relapse?
- Relapse is a common occurrence
- 90% of clients will experience a lapse within 12 months of completing treatment (brief return to use)
- 60% of clients will experience a relapse (return to old patterns) within 12 months
What is the shape of the change model?
spiral - stages of change are not usually linear and organised in practice. Typically cycle back and forth several times. Each time learning more about themselves and triggers for relapse
what are the strategies for facilitating movement through the stages of change?
motivational interviewing - descisional based.
• Does not mean that MI and Stages of Change aka ‘Trans-theoretical Model’ are the same thing!
what is motivational interviewing?
“ A directive, client-centred approach for initiating behaviour change by helping clients to explore and resolve ambivalence.”
(Rollnick and Miller, 1995)
what is the motivational interviewing spirit?
collaboration, evocation, autonomy
what should you do in motivational interviewing?
Think about a behaviour or habit that you would like to change but have not been able to achieve this yet
o What stops you from making the change?
o How do you react when others ask you how you are going with making the change?
what is collaboration in the spirit of motivational interviewing?
o Client centred and driven
o Partnership not ‘expert’/‘recipient’
what is evocation in the spirit of motivational interviewing?
o Designed to elicit clients own motivations
o ‘Change-talk’
what is Autonomy in the spirit of motivational interviewing?
o Ultimately the client is responsible for change
o Freedom to choose the direction
what is decisional balance in MI?
perceived advantages (pros) and disadvantages (cons) of problem vs change
what are the assumptions with regards to decisional balance in MI?
motivation for change affected by decisional balance
What can decisional balance in MI assist in?
Can assist in assessment of stage of change
what are the 4 general principles of MI?
- Express Empathy
- Develop Discrepancy
- Roll with Resistance
- Support Self-Efficacy
What is the express empathy principle of MI?
o Acceptance facilitates change
o Ambivalence is normal
o Skillful reflective listening is fundamental
What is the develop discrepancy principle of MI?
o Use clients own motivators to highlight discrepancy between present behaviour and important personal goals or values
o ‘Psychological squirm’
what is the roll with resistance principle of MI?
o Avoid arguing for change
o Resistance not directly opposed, signal to respond differently
o Client is primary resource for solutions
What is the support self-efficacy principle of MI?
o Client’s belief in possibility for change - important motivator
o Client responsible for change
o Counsellor’s belief in client also important
What is the efficacy of MI?
• Support for the use of MI in several clinical trials (e.g. meta-analysis by Noonan & Myers, 2007)
• Support for use in brief settings of 15 mins, superior to simple advice giving (Rubak et al., 2005)
• Greatest support for changing substance use-
Possibly not as effective with nicotine
• Also support for use in changing other health behaviours and counselling settings
o E.g. Diet, exercise, employment, educational achievement, relationship counselling, criminal behaviour, child safety, DV
what are the critiques of MI?
- Large variability in effectiveness
- Confusion with Trans-theoretical model
- Not stand alone intervention, useful as adjunct to more intensive treatment
Why is there large variability in effectiveness of MI?
o Causal process remains unclear
o Training/Processes variations in session?
o Technique has changed over time, but is there quality control in place?
Why is MI not a stand alone intervention?
MI may raise motivation to change, but the client still needs the skills and knowledge required to change
what is the traditional view of how we can motivate people to change?
Use pressure and force
o Reasons for change come from counsellor/society/others
o Break down resistance through shame, guilt, loss, threat, anxiety, or humiliation
o Ambivalence - sign of denial
o Outcome: SHORT-LIVED CHANGES
What is the alternative view of how we can motivate people to change
develop personal desire
o Motivate by focus on what is important or valued - Their own reasons to change
o Helping person to feel accepted and empowered
o Respect autonomy, choice and personal responsibility for change
o Ambivalence normal - part of the process
o Outcome: LONG-LASTING CHANGES
