Module 5: Comorbidity and the role of family and friends

Question 1

Prevalence of SU + comorbid disorders

Answer 1

• 19,1% has ever had a SUD
• 5,6% during the last 12 months

Question 2

Addiction often does not exist in isolation

Answer 2

• 50% of clients in treatment suffers from another mental disorder
• 25% suffers from comorbid mood or anxiety disorders
• especially mood disorders, anxiety disorders, ADHD, personality disorders

Question 3

The relevance of comorbidity
(5)

Answer 3

• More severe symptoms
• Lower treatment compliance
• Higher drop-out
• Worse treatment outcome
• Higher probability of relapse
  -Also in the disorder they are comorbid

Question 4

Explanatory models of comorbidity

Self-medication hypothesis

Answer 4

mental disorder causes the excessive use of a substance
- e.g., to control emotional pain

Question 5

Explanatory models of comorbidity

High-risk hypothesis/Susceptibility hypothesis

Answer 5

Excessive use of a substance causes the mental disorder
- e.g., by leading to behavior that increases the risk for trauma exposure (high-risk hypothesis)
- e.g., through biological processes introduced by substance use that render someone more susceptible to developing PTSD (through traumatic event) (susceptibility hypothesis)

Question 6

Explanatory models of comorbidity

Third-factor hypothesis

Answer 6

association occurs because SUD and the other mental disorder share the same cause
- e.g., abnormalities in the same brain region, genetics or environmental risk factors/triggers

Question 7

Explanatory models of comorbidity

Bidirectional hypothesis

Answer 7

SU and other mental disorders influence one another
- e.g., thinking that drinking helps improve mood -> instead increases susceptibility to mood disorders -> the disorder makes you feel like yiu need to drink more

Question 8

Alcohol: influence on psychological symptoms

Answer 8

• Depressed mood
  -Often times clients do not see their substance use as problem/ they are ashamed so they are not inclined to tell you about it unless you ask
  -There is an enormous effect on comorbid disorders
  -If it goes unnoticed, treatment wont work for clients and their time is wasted
• Fear
• Confusion
• Mood swings
• Sleep problems
  -not about falling asleep, drinking helps falling asleep. Problem with waking up within 2 hours and quality of sleep

Question 9

Alcohol withdrawal <8-12h
(3)

Answer 9

• general bad/sick feeling
• headache, nausea, vomiting
• light shaking, fear, not eating

Question 10

Alcohol withdrawal: 12-36h
(4)

Answer 10

• insomnia
• restless, agitation
• tremors
• sweating. palpitations

Question 11

Alcohol withdrawal: 48 hours
(6)

Answer 11

• withdrawal feeling/ delirium (confusion)
• tremor
• sweating
• agitation
• slight fever
• hypertension

Question 12

a note about withdrawal symptoms overlapping with symptoms for comorbid disorders:

Answer 12

Easy to label these for other disorders but if they go away after a week of not drinking, then you cannot label them as another disorder
- you have evidence of a temporal relationship in which symptoms go away with abstinence

Question 13

Cannabis: influence on psychological symptoms
(4)

Answer 13

• concentration issues
• memory impairment
• fear
• suspicion, paranoia, psychosis, anxiety

remember that withdrawals come with repeated drug use and not just when you smoke 1 joint one time

Question 14

Cannabis: withdrawal symptoms (3)

Answer 14

• insomnia
• depressed mood
• agitation

-> these go away between 4-6 weeks after abstinence

Question 15

Cocaine: influence on psychological symptoms (5)

Answer 15

• Lack of energy
  -usually people take it to feel energized but long-term use makes you tired
• Depressed mood
• Insomnia
• Fear and panic
• Suspicion / paranoia

Question 16

Substance use and depression: diagnostic facts

Answer 16

• A lot of comorbidity between depression and excessive alcohol use

-patients who are referred to Jellinek are those that initially came in for depression but are told to quit drinking first (they are angry because they don’t see a problem with their drinking)

• in about 80% of the clients, symptoms of depression disappear after quitting alcohol –> important to ask client to quit first (treatment for depression will not work as alcohol is the underlying problem)
• clients often perceive substance use as self medication so it is helpful to make a timeline –> to show them that symptoms of depression started around a time when they started drinking

Question 17

Substance use and anxiety

Answer 17

• Symptoms can be the result of substance use: intoxication and withdrawal symptoms may look like anxiety symptoms
• Substance use may also have masked anxiety disorder
  -e.g., using a substance to make yourself function well in the face of anxiety disoders
  -If anxiety disorder was there before the substance abuse it will not go away after abstinence -> masking
• Anxiety disorders can maintain substance use and cause relapse
  -maintain substance use, because you take substance to downgrade symptoms
  –> as soon as you stop taking substance you will relapse
• Anxiety decreases after alcohol abstinence, returns after relapse

Question 18

note about benzodiazepines as a medicine to cope with strong anxiety symptoms after quitting substance use

Answer 18

they are themselves highly addictive and if you happen to use them long enough to get addicted the detoxification process takes even longer than in alcohol

-> if you have to choose between alcohol or benzos, choose the alcohol

Question 19

Substance use and PTSD

Answer 19

• Prevalence post-traumatic stress disorder (PTSD) 11-41% among people with substance abuse disorder
• Abstinence is not required for diagnosis of PTSD
  -Can be diagnosable through every substance
  -Substance used to diminish many symptoms
  -Yet there are some symptoms that still come up as a result of substance use (you can assess PTSD even though someone is still using drugs)
• Integrated treatment is indicated
• Exposure is possible!
  -E.g., get clients to talk about their worst nightmare over and over again
  -Patients listen to a recording of this repeatedly
  -Highly effective although it does ask a lot from patients -> clinicians are scared that this will make patients take more drugs (not true, so use it)

Question 20

substance use and PTSD: why do they co-occur? (5)

Answer 20

1. At-risk hypothesis (Chilcoat et al.1998): substance useincreases the risk of trauma (e.g., because of theexternal environment or more risky behavior)
2. Self-medication hypothesis (Khantzian, 1997): more substance use to cope with PTSD > most supporting evidence
3. No habituation trauma due to being under the influence (Steward et al., 2002)
   -The brain’s natural process or processing traumatic events is disrupted when substances are used
   –> increased risk of developing PTSD
4. Substance use triggers symptoms
   -E.g., having a racing heart from withdrawals can also be labelled as something that arises from trauma
   -the way you label it has an effect on the way you think about it -> increases your anxiety
5. Third-factor hypothesis: Underlying causal factor (e.g., genetic predisposition / vulnerability)

Question 21

Diagnosing anxiety disorders, guideline

Answer 21

• in accordance w/ guideline it is preferable to wait 2-3 weeks before diagnosis (patient has to be abstinent) , during which time screening can take place immediately

exceptions:
* SAD
-exception because being scared of social situations is not a withdrawal symptom –> cannot cloud your judgement about whether this is SAD or AUD –> same idea with the other ones here
* OCD
* Specific phobia
* PTSD
* GAD
-In GAD you worry a lot
-if you use alcohol for a long time, these worries become realistic (alcohol use influencing functioning at work) You will have to wait until end of treatment of substance abuse because as long as worries are realistic, they are not a disorder. (you need to exclude the real worries and see if there are still some worries that seem exaggerated)

Question 22

Substance use and ADHD

Answer 22

• Prevalence ADHD in substance abuse: 23.1% (2.5-3.4% general population)
• Trimbos found: 1/5 of people suffering with substance abuse may have ADHD in adulthood
• Many clients with ADHD use alcohol, cocaïne, amphetamines and cannabis > self-medication
  -To ease the overthinking mind
  -Either via a downer (cannabis or alcohol) or upper (cocaine/amphetamines) –> makes you think so much that at some point it calms itself)
  -1st reduces racing thoughts
  -2nd makes you concentrate better
  -Slow releasing medications in order to prevent dependability
• Medication is less succesful: CBT is preferred treatment
  -because medicine that are used are quite addictive (e.g., amphetamines)
  -you want to turn to slow releasing medications in order to prevent dependability
• Protocol ADHD and Addiction (Trimbos, 2004)

Question 23

Diagnosing ADHD

Answer 23

• Especially high prevalence in relation with alcohol abuse
• You can diagnose this even when substance use is still going on
  -much information from their childhood (ADHD starts in childhood) like reports etc. or someone who is close to them to tell you their symptoms
• Diagnosing ADHD while people are still using alcohol is challenging because the symptoms overlap with effects of alcohol and withdrawal. Anamnestic information from a parent is important.

Connection to PTSD
If both are present, PTSD addressed first because it overlaps with ADHD symptoms
-and sometimes when PTSD is out of the equation ADHD will too

Question 24

Substance use and bipolar disorder

Answer 24

• 50% of patients with bipolar disorder alsosuffers from substance abuse
• Diagnosis is challenging because of overlap with symptoms of substance-induced intoxication
  -especially during manic phases
• Relatively little research in this area
  –> Follow regular guidelines

Question 25

Substance use and personality disorders

Answer 25

* Especially borderline and anti-social personality disorders are prevalent * **Anti-social behavior can be a consequence of addiction** -make sure someone has a period of time in their adulthood when they were sober so they can reflect on that while you do diagnostics -because most people do exhibit antisocial behavior when they are on cocaine and narcissism * Screening only indicated if suicidality or self-harm interferes with treatment -Because its a very intense treatment -> only if patient wants or when suicidal thoughts

Question 26

Substance use and psychotic symptoms

Answer 26

* Low prevalence of schizophrenia -due to low prevalence in the population -but also due to this population's difficulty of reaching out for help (they withdraw from society) * Psychotic symptoms occur while under the influence; or during withdrawal. -e.g., anyone will experience hallucinations after taking speed and not sleeping for a few days --> not necessarily a psychosis * Cannabis use > psychosis / schizophrenia if you are vulnerable to it -self induced psychosis * However: also often suspicion/paranoia with excessive use of cannabis / cocaine, that disappears after quitting drugs * Delirium during alcohol withdrawal

Question 27

Conclusions diagnostics

Answer 27

* Diagnosis of syndromes disorders in substance abuse is challenging * that's why in the there is a criteria in the DSM-V: symptoms not due to direct physiological effects of substance * abstinence is preferable but ofc we do not live in a perfect world so its not always achievable -if not possible you will have to use a timeline * 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) * Consider clinical admission if abstinence is difficult to achieve

Question 28

Advice for dual disorder treatment: what is needed for an effective treatment 1/2

Answer 28

* for an effective treatment of co-morbid disorder, it is ideal to have a period of abstinence -if you treat a comorbid disorder while patient uses substance its like painting in the rain (some of it sticks but its not gonna be pretty) * co-morbid disorders can be treated effectively without changing anything in substance abuse --> but this will have no effect on the use of the substance -ppl are still vulnerable for explanatory models about how substance abuse coincides with comorbid disorder --> addiction has to be treated anyways

Question 29

Advice for dual disorder treatment: what to do for disorder in which there is no evidence based integrated treatment? 2/2

Answer 29

* recommended to follow regular treatment guidelines for this disorder -**start as soon as possible** * multidisciplinary guidelines and treatment protocols in parallel -e.g., for some substances there are medical treatments possible (e.g., methadone for heroin) * psycho-education regarding relationship between use and psychological symptoms using functional analysis * consider risk situations for substance use -e.g., if you do an anxiety treatment to have client practice with social situations do not send them into a bar (making it unnecessarily hard for them)

Question 30

Sobering results

Answer 30

* Effects of addiction treatments in patients with severe psychiatric conditions are **insufficient** * regular evidence-based treatments for comorbid disorders can be used for patients with addiction (e.g., if they don't want to change their use of substances) * using these treatments does not escalate the addiction problems * however, they have no effect on the addiction itself

Question 31

Dual diagnosis in practice

Answer 31

* GGZ registration> referral to addiction care * Registration GGZ > underestimation of substance use -people do not mention substance use, you have to ask for it * Registration for addiction care> underestimation of psychological symptoms -other way around happens as well --> people don't feel heard when they come in for depression and are told that they need to be abstinent first for a while * Due to long waiting lists / relapse, clients are often sent back and forth between psychiatric and addiction services and fail to receive proper diagnosis/treatment --> e.g., after treating someone's addiction we look for a diagnosis of depression and then they are sent to a psychiatric service on a waiting list --> they relapse while on the waiting list so by the time they get to the psychiatric institution they are sent back to Jellinek because of substance use and the cycle continues HORRIBLE

Question 32

Solution? work together!

Answer 32

* Consultation -call a colleague to see if they have time to squeeze in their schedule * integrated treatment * treatment at one location

Question 33

how many of those with substance abuse also have comorbid psychological symptoms + what are the most common disorders

Answer 33

50%!!! * mood disorders * anxiety disorders * personality disorders * ADHD patients with comorbid disorders have a worse prognosis

Question 34

Some psychological complaints can be caused or exacerbated by substance abuse, what is adviced to be done in these cases

Answer 34

treat or address the substance abuse first and THEN look at comorbid disorders

Question 35

The difficulty in helping a loved one struggling with addition comes from (3)

Answer 35

* the fact that you may get a lot of conflicting ideas about what to do * some will say you have to completely disconnect or act harshly * others say you need to support and protect

Question 36

What are some other issues that close relatives of those struggling with addiction

Answer 36

1-dealing with difficult emotions: * sadness * depression * anger * guilt * shame * frustration * powerlessness * insecurity 2- other issues * conflicts * domestic violence * financial problems * disrupted relation with their children * relationship problems * sexual issues

Question 37

what do relatives or closed ones therefore need as well

Answer 37

help to cope with negative consequences for their own well-being and mental health, as well as that of their family

Question 38

Treaments that take the role of relatives or closed ones into account (4)

Answer 38

1. Al-Anon (based on the twelve steps of the AA) 2. Johnson intervention (also known as "confrontational intervention") 3. CRAFT (Community Reinforcement and Family Training) 4. BCT (Behavioral Couple Therapy)

Question 39

Johnson intervention

Answer 39

addict is unexpectedly confronted by his or her close relatives and/or friends - radical, direct, confrontational with regard to the negative consequences of substance abuse - seen as the last chance to reach out and rescue the addict as a matter of life-and-death - little empirical support

Question 40

Al-anon

Answer 40

based on the 12-steps of the AA. To help the close relatives accept that they are powerless and to help "detach with love" * “Do not reprimand the alcoholic, do not moralize, do not swear, do not accuse, do not threaten, do not beg, do not argue, don't throw away any drink, don't lose your temper, and don't stand for the consequences of his / her drinking. You may feel better, but the condition is getting worse. * Do not get angry, because then you will hurt yourself and with it the opportunity to help. * Don't let your fear tempt you to do things that the alcoholic needs to fix himself. * Don't accept promises, because that's only a way to delay pain. Don't change anything you agreed upon. If something has been agreed upon, stick to it. * Don't believe everything the alcoholic tells you, it could be a lie. * Do not let the alcoholic exploit or abuse you, because that way you are participating in his game: avoiding responsibilities. * Keep recognizing that alcoholism is an ever-worsening disease that grows in severity if the drinking continues. ”

Question 41

CRAFT

Answer 41

protocolized treatment in which **close relatives are supported by the practitioner to adjust their behavior in order to motivate the patient to start treatment.** -> based on MI and CBT -> also aims to improve quality of life of relatives -> convincing evidence

Question 42

2 central principles of CRAFT based on learning psychology

Answer 42

1. Positive reinforcement of desirable behavior -e.g., verbal positive reinforcement in response to a clean, sober lifestyle 2. Not rewarding *unwanted* behavior and allowing negative reinforcement -e.g., not protecting the addicted individual from natural negative consequences of abuse -> For example, the close relative does not intervene when this person has drunk too much and overslept the next morning and therefore misses an important meeting. There must be a reason or motive for addressing the problem.

Question 43

BCT (behavioral couples therapy)

Answer 43

aims to 1. teach the couple effective ways to cope with substance related situations 2. teach the partner to support/reinforce behavior change and sobriety 3. improve relationship satisfaction and reduce stress (to prevent relapse) -by enhancing positive exchanges between partners -boosting healthy communication patterns -boosting problem solving skills

Question 44

what is a protective factor for relapse and what is unfortunate about the treatment that most directly fosters it (BCT)

Answer 44

Relationship satisfaction. BCT is expensive and intensive --> only recommended when individual therapy is ineffective - when there are severe triggering relatonship issues - and only when the partner is willing to be involved in treatment