L5 - Comorbidity and the role of family and friends Flashcards
1
Q
What is the prevalence addiction in general population?
A
- 19.1% has ever had a substance use disorder
- 5.6% during the last 12 months
- Difficult to estimate due to the use of different substances as a criteria
2
Q
What is the comorbidity prevalence among SUD patients?
A
- 50% of clients in substance use treatment suffers from another mental disorder (‘dual diagnosis’)
- 25% suffers from comorbid mood or anxiety disorders
- Especially mood disorders, anxiety disorders (PTSD), ADHD, personality disorders
- 1/4 clients in Jellinek suffer from PTSD
- There is not much known on how many people with other mental health disorders also suffer from SUD but they estimate around 50%
3
Q
Why is it relevant to look at other disorders?
A
When SUD is comorbid with other disorders or other disorders are comorbid with SUD then there are:
- More severe symptoms
- Lower treatment compliance
- Higher drop-out
- Worse treatment outcome
- Higher probability of relapse
4
Q
What are the 4 theories that try to explain why does substance abuse oftenco-occur with other mental disorders?
A
- Self-medication hypothesis
- Susceptibility hypothesis
- High risk hypothesis
- Bidirectional hypothesis
- 3rd factor hypothesis
Picture 1
5
Q
What is the Self-medication hypothesis?
A
Mental disorder -> excessive use of a substance, because substances are used to control emotional pain
6
Q
What is the susceptibility hypothesis?
A
- Excessive use of a substance -> mental disorder
- For example, if you label withdrawal symptoms as symptoms of a panic attack, you can enter the panic attack circle (you basically evoke panic attacks) and hence develop panic disorder
- For example, through biological processes introduced by substance use that render them more susceptible to developing PTSD following exposure to traumatic event
7
Q
What is the high-risk hypothesis?
A
- Excessive use of a substance -> mental disorder
- Using substances, you may have lower boundaries and impulse control, so you engage in behaviours that increase the risk for, for example, trauma exposure
8
Q
What is the bidirectional hypothesis?
A
Substance use and other mental disorders may also influence each other / have bidirectional interrelations
9
Q
What is the 3rd factor hypothesis?
A
- There is no direct relationship, but the association occurs because substance use disorder and the other mental disorder share the same cause (i.e., third factor)
- For instance, abnormalities in the same brain regions, genetics, or environmental risk factors or triggers
- E.g. low impulse control in ADHD and SUD are a common factor
- E.g. susceptible to be influence by people - personality disorder and SUD
10
Q
Why is it important to recognise the symptoms of use of a substance in clinical field?
A
- Some clients might be ashamed to talk about their addiction so they will withhold this information unless they are directly asked
- So it’s important to always ask about substance use in an intake interview because some presenting symptoms of substance use are very similar to some of the mental conditions
11
Q
What is the alcohol’s influence on psychological symptoms?
A
- short-term: can make depressed mood even worse
- fear - especially if drinking so much that you lose control
- confusion
- mood swings
- sleep problems - quality of sleep reduced and people wake up during the night
12
Q
What are the withdrawal symptoms of alcohol?
A
< 8-12 hours (hangover):
- General bad/sick feeling
- Headache, nausea, vomiting
- Light shaking, fear, not eating
12-36 hours:
- Insomnia
- Restless, agitation
- Tremors
- Sweating, palpitations
48 hours:
- Withdrawal feeling / delirium - confusion where a person is, what time it is…
- Tremor
- Sweating
- Agitation
- Slight fever
- Hypertension
Some of these can be symptoms of other mental disorders - if they go away after a week of not drinking then they were alcohol induced and we cannot label them for another disorder
13
Q
What is cannabis’ influence on psychological problems?
A
- Concentration issues
- Memory impairment
- Fear
- Suspicion / paranoia / psychosis
14
Q
Withdrawal symptoms of cannabis
A
- Insomnia
- Depressed mood
- Agitation
They go away after 2 to 6 weeks
15
Q
What is cocaine’s influence on psychological symptoms?
A
- lack of energy
- depressed mood
- insomnia
- fear and panic
- Suspicion / paranoia
16
Q
Do substances must be quit before a client can be diagnosed with psychological symptoms?
A
- Yes, you can’t properly diagnose someone as the symptoms of withdrawal and mental disorders are very overlapping so it’s not clear
- So to do proper diagnostics, a client must always quit using substances first
17
Q
How is substance use and depression related?
A
- A lot of comorbidity addiction and depression, especially in the case of excessive alcohol consumption
- In about 80% of the clients, symptoms of depression disappear after quitting alcohol - that’s why it’s so important they first quit before diagnostics
- However, clients often perceive their substance use as self-medication!! > timeline can be helpful
18
Q
How is substance use and anxiety related?
A
- Much overlap between anxiety symptoms and the effect of substance and abstinence (withdrawal)
- Advice: quit substance for 2-3 weeks to see whether the symptoms decrease and only then diagnose if the symptoms are still there
- Symptoms can be the result of substance use: intoxication and withdrawal
- Substance use may also have masked anxiety disorder
- Anxiety disorders can maintain substance use and cause relapse
- Anxiety decreases after alcohol abstinence, returns after relapse
- !!Be careful: some doctors prescribe benzodiazepines to help with quitting SU but they are highly addictive and have much longer detoxification period than for example alcohol + there are no medications to help with dealing with withdrawal symptoms
19
Q
Which anxiety disorders have an exceptions from waiting 2-3 weeks after abstinence before diagnosis?
A
- Social anxiety disorder - being scared of being socially anxious is not a withdrawal symptom
- OCD - it’s very specific and its symptoms are not a withdrawal symptom
- Specific phobia - same as OCD and SAD
- PTSD - its symptoms overpower the symptoms of SUD
- !!GAD - its symptoms become realistic worries as people have relational, financial and occupational problems because of SU so it’s tied to the SU so here you wait until you finish the treatment of SU to eliminate all the realistic worries (even if they are about everything)
20
Q
How is substance use and PTSD related?
A
- Prevalence post-traumatic stress disorder (PTSD): 41% among people with substanceabuse disorder - numbers differ due to methodological differences
- Abstinence is not required for diagnosis of PTSD - you can assess it even when someone uses substance
- Integrated treatment is indicated - try to start treatment as soon as possible
- Exposure is possible! - doesn’t induce more drug taking and it’s highly effective
21
Q
Why does SU and PTSD co-occur?
A
- At-risk hypothesis: substance use increases the risk of trauma (e.g., because of the external environment or more risky behavior)
- Self-medication hypothesis: more substance use to cope with PTSD > most supporting evidence
- No habituation trauma due to being under the influence - the brain can’t properly process it because the substance is clouding it
- Substance use triggers symptoms - the way patients label their symptoms influences how they think about them and hence whether their anxiety about the symptoms will increase
- Underlying causal factor (e.g., genetic predisposition / vulnerability)
22
Q
How is SU and ADHD related?
A
- Prevalence ADHD in substance abuse: 23.1% (2.5-3.4% general population)
- Trimbos study: 1/5 of people suffering with substance abuse may have ADHD in adulthood
- Many clients with ADHD use alcohol, cocaïne and cannabis > self-medication
- Medication is less succesful: CBT is preferred treatment
- Protocol ADHD and Addiction
23
Q
How is diagnosing ADHD while people use substances?
A
- You can diagnose ADHD when they’re still using but they have to be able to provide info about their childhood or have someone with them (i.e. parent) to give such info (or alternatively use report cards from elementary school)
- Nevertheless, diagnosing ADHD while people are still using alcohol is challenging because the symptoms overlap with effects of alcohol and withdrawal
24
Q
How is SU and bipolar disorder?
A
- 50% of patients with bipolar disorder also suffers from substance abuse
- Diagnosis is challenging because of overlap with symptoms of substance-induced intoxication
- Relatively little research in this area
- Follow regular guidelines - so do both protocolized treatments next to each other
25
How is SU and personality disorders related?
- Especially borderline and anti-social personality disorders are prevalent
- Anti-social behavior can be a consequence of addiction - there must have been a period of time when they were sober and still did anti-social behaviour
- If the client doesn't want to change (doesn't want treatment) you don't even do the screening because it's quite intensive assessment (2hr interview)
- Screening only indicated if suicidality or self-harm interferes with treatment
26
How is SU and psychotic symptoms related?
- Low prevalence of schizophrenia - partly because low prevalence in general population but also because this is a group that finds it very difficult to get help
- Psychotic symptoms occur while under the influence or during withdrawal
- Cannabis use -> psychosis / schizophrenia **if and only if** vulnerable
↪ if family history of schizophrenia - don't use cannabis!
↪ cannabis cannot induce schizophrenia, only strengthen it if you're brain is vulnerable to psychosis / schizophrenia
- However: also often suspicion/paranoia withexcessive use of cannabis / cocaine, that disappears after quitting drugs
- Delirium during alcohol withdrawal
27
Conclusions diagnostics
- Diagnosis of syndrom disorders in substanceabuse is challenging
- DSM-V: the symptoms are not due to the direct physiological effects of a substance
- absence is prefferable but sometimes it's not achievable then use a timeline and create hypothesis as to which one was first; you can try different treatments and see what helps - you have to work with what you have
- Screening at intake: PTSD, ADHD, anxiety and mood disorders using short questionnaires
- Guideline of the Dutch Association of Mental Health and Addiction Care (‘GGZ’ guideline): 2-3 weeks of alcohol abstinence for diagnosis of other syndrom disorders with structured interview (SCID / MINI / CAADID)
- No general guidelines for other substances. Suggestion is the half-life of the drug
- Exceptions to this are social anxiety, OCD, specific phobia and PTSD
- An exception is also generalized anxiety disorder (GAD)(longer abstinence)
- If no abstinence: try to draw up a timeline with substance use and complaints -> draw up hypotheses
- Consider clinical admission to general hospital for 6 weeks if abstinence is difficult to achieve - to keep them sober and allow you to do proper diagnostics (challenging - no hospital will do it for 6 weeks)
28
What is the advice for dual disorder treatment?
- For an effective treatment for co-morbid disorders, patients/clients are abstinent from all substances, ideally
- Co-morbid disorders can be treated effectively, but this treatment has no additional effect on the addiction
- So addiction will have to be treated anyway!
- For co-morbid disorders for which there is no evidence-based integrated treatment, it is recommended to follow the regular treatment guidelines for this disorder, but starts as soon as possible for any treatment
- Multidisciplinary guidelines and treatment protocols in parallel
- Psycho-education regarding relationship between use and psychological symptoms
- Functional analysis is important - can give a lot of psychoeducation
- Consider risk situations for substance use (e.g. don't send someone to a bar to train their social skills)
29
What are the treatment expectancies for people with comorbid disorders?
- Effects of addiction treatments in patients with severe psychiatric conditions are insufficient
- Regular evidence-based treatments for cooccuring disorders can be used for patients with addiction (if they don’t want to change there use of substances)
- Using these treatments do not escalate the addiction problems
- However, they have no effect on the addiction…
30
How does dual diagnosis look like in practice?
- GGZ (general mental health department) registration> referral addiction care
- Registration GGZ - underestimation of substance use
- Registration for addiction care - underestimation of psychological symptoms
- Due to waiting lists / relapse, clients are often sent back and forth between psychiatric and addiction services and fail to receive proper diagnosis/treatment
31
Is there a solution to this problematic way of practice?
Work together!
- Consultation
- Integrated treatment
- Treatment at one location
32
What do they do at Jellinek?
- We offer PTSD-treatment and ADHD-coaching and –medication parallel to our treatment for addiction
- We offer diagnostic assessment for symptoms that remain after 3-4 weeks of abstinence
- If needed, we offer treatment for some comorbid disorders, like depression and anxiety, especiallyif the symptoms interfere with our treatment
- We offer Dialectical Behavior Therapy for clients with Borderline personality disorder
- We are trying to set up a dual treatment course with NPI, specialists in personality disorders
33
Leaning objectives
1. Describe why substance abuse often co-occurs with other disorders (4 explanatory models) [paraphrasing]
2. Name or recognize psychological symptoms that are induced by addictive substances and withdrawal [paraphrasing]
3. Indicate why it is important for diagnosis and treatment to consider comorbidity [analyzing]
4. Knowledge of common co-morbid substance abuse disorders [paraphrasing]
5. Recognize diagnosis of addiction and comorbid disorder for a case [evaluating]
6. Give advice on (the order of) diagnosing and treating substance abuse and comorbid disorders [independent thinking]
