Task 4 Flashcards
ECA study:
— 37% of people with alcohol disorders and 53% with other drug disorders have comorbid psychiatric conditions
— Gregg et al. – four general explanations for high rates of substance abuse among people with schizophrenia:
— Substance abuse causes schizophrenia (cannabis)
— Schizophrenia and substance abuse maintain each other
— Substance use as self-medication
— Common etiological factors of schizophrenia and substance abuse
emotional, social, and biological sequelae of early childhood trauma may constitute an increased vulnerability in both conditions
Treatment issues regarding people with dual diagnosis
In comparison to substance abuse only:
— less motivation to change, harder to engage, drop out of long-term programs more easily, and make slow progress
— Features of psychosis may inhibit progress in any treatment phase
Features of psychosis may inhibit progress in any treatment phase e.g.
— people with schizophrenia:
— low tolerance of stressors
— narrow repertoire of coping skills
— frequently develop idiosyncratic avoidance methods to manage positive symptoms (= delusions, auditory hallucinations, concrete thinking, and inferential thinking)
— Prochaska and DiClemente – 5 stages of readiness to change:
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance
3 aspects of schizophrenia that constitute barriers to making sign
Personal changes:
- lack of motivation
- impaired cognition
- social-skills limitations
Psychological interventions for Dual Diagnosis
Individual approaches
Motivational Interviewing (MI)
– Essential in early stages of working with dually diagnosed
– Individual may not consider that they have a problem
– MI emphasizes personal choice, responsibility, and awareness of the risks and benefits of continued substance use
– Aim to assist clients making links between life goals and problems related to substance use
– Written treatment plan with clear goals may be developed
Cognitive-behavioral therapy (CBT)
– Six issues with dual diagnosis must address:
– Recognizing escalating symptoms and other warning signs
– Coping with cravings
– Coming up with healthy alternative activities
– Normalizing substance-use lapses
– Developing plans for lapse/ relapse
– Cognitive restructuring to counteract positive beliefs about substance use
— Family support may enhance both individual and group treatment approaches
Psychological interventions for Dual Diagnosis
Group interventions
— Relapse-prevention approaches – have to be tailored to each participants abilities and style
— Most effective when staged approach addresses issues assoc. with the actual motivation level of each participant
— Offer essential support
— Traditional 12-step approach: unhelpful for people with dual diagnosis
— Assertive community treatment (ACT) – structured health care service approach
— By adapting a conventional model of case management to needs of this client cohort
— ACT clients achieve better outcomes with regard to substance use and quality of life, but equivalent on all other measures
— Lower-intensity treatment
— Greater freedom to leave facility, daily attendance at a community-based treatment program for reducing substance use, less responsibility of peers for each other, more direct staff involvement with clients, and shorter, less-intense therapy sessions
— Better outcomes and one- and two-year follow-ups
Group interventions advantages
— potential to change social attitudes and behaviors
— and generally cost-effective
Potential treatment models
- Sequential treatment – person is treated for one condition, then the other
- Parallel Model – treatment for both disorders at the same time, though the service providers work in isolation from each other
- Integrated treatment – targets both conditions simultaneously (either through coordinated interaction between service providers or their working together as one team)
– Require mental health staff to coordinate a range of approaches (such as detoxification, medication management, CBT, and MI)
Initial focus when developing treatment plans:
— encouraging a therapeutic alliance with the client and on offering MI, relapse prevention, and case management
Treatment principles
Treatment principles
— engagement strategies,
— motivational counseling,
— stage-wise interventions,
— active treatment,
— long-term program retention,
— integrated mental illness and substance abuse treatments
— relapse-prevention strategies
Ú further comprehensive services:
— peer support
— family education and interventions
— liaison with the criminal justice system
— housing
— vocational rehabilitation
Diminished control
Diminished control – is a core defining concept of both substance dependence and behavioral addictions
Similarities of bhavioral addictions and SUD
— Failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or others
— Repetitive engagement in these behaviors ultimately interferes with functioning in other domains
— Onset in adolescence and young adulthood
— Natural histories may exhibit chronic, relapsing patterns
ego-dystonic
— over time behaviors become more less ego-syntonic and more ego-dystonic
— less pleasure, more habitual/compulsive
— motivation by less positive reinforcement, more negative reinforcement
Personality of Behavioral addictions
Behavioral addictions and SUDs high on self-report measures of impulsivity and sensation-seeking and generally low on measures of harm avoidance
Internet addiction or pathological gambling high levels of harm avoidance
OCD high on harm avoidance and low on impulsivity
— High scores on measures of impulsivity and sensation-seeking
— Low scores on measures of harm avoidance
— High levels of compulsivity may be limited to impaired control over mental activities and worries about losing control over motor behaviors
— Internet addiction: Aspects of psychoticism, interpersonal conflict, and self-directedness may play role
— OCD: high on harm avoidance and low on impulsivity
Comorbidity
Comorbidity
— Gambling and SUD: high rates of co-occurrence in both directions
— Highest odds ratios between gambling, alcohol use disorders, and antisocial personality disorders
— Data must be interpreted cautiously
— causal association may manifest on a behavioral level (e.g., alcohol use may disinhibit range of inappropriate behaviors) or on a syndromal level (e.g., behavioral addictions may start after alcoholism treatment as substitute for drinking)
Neurocognition
— Study: gamblers and alcoholics both showed diminished performance on test of inhibitions, cognitive flexibility, and planning tasks, but had no differences on tests of executive functions
Serotonin & Behavioral addictions
Serotonin => inhibition of behavior
— Low CSF 5-HIAA levels correlate with high levels of impulsivity and sensation-seeking
— Found in pathological gamblers
Dopamine & Behavioral addictions
Dopamine => learning, motivation, and the salience of stimuli (reward)
— Underlying biological mechanism for urge-driven disorders may involve the processing of incoming reward input by the ventral tegmental area/nucleus accumbens/orbital frontal cortex circuit
— Contain neurons that release dopamine to nucleus accumbens and orbital frontal cortex
— Ventral tegmental area (VTA) releases DA to NA and OFC
— Alterations in DA pathways seeking of rewards
— Parkinson’s patients:
— 6% experienced new onset of behavioral addiction or impulse control disorder due to treatment
— Substantially higher rates with dopamine agonist medication
— Antagonists at Dopamine D2/D3 receptors enhance gambling-related motivations and behaviors in non-PD individuals with pathological Gambling and have no efficacy in the treatment of pathological Gambling
Common neurobiological processes & Behavioral addictions
— Diminished activity of vmPFC impulsive decision making in risk-reward assessments and decreased response to gambling cues in pathological gamblers
— Similar abnormalities found in people with SUD
— Dopaminergic mesolimbic pathway from the VTA to the NA may be involved in both SUD and path Gambling
Family History/ Genetics
— First-degree relatives: sign. Higher lifetime rates of alcohol and other SUDs, depression, and other psychiatric disorders
— Twin studies: two-thirds of the co-occurrence between pathological gambling and alcohol use disorders was attributable to genes that influence both disorders
— Increase in frequency of the D2A1 allele of the D2 dopamine receptor gene (DRD2) from individuals with non-problematic gambling to those with problematic gambling
— Excessive internet users: higher frequencies of the long-arm allele (SS) of the serotonin transporter gene (5HTTLPR) assoc. with higher harm avoidance
Responsiveness to treatment
Responsiveness to treatment
— Often respond to the same treatments as patients with SUDs
— 12-step self-help approaches, motivational enhancement, and cognitive behavioral therapies
— no medications currently approved
— those used for SUDs also look promising for treating behavioral addictions
— e.g., mu-opioid receptor antagonist
— Studies:
— glutamatergic modulation of dopaminergic tone in the NA may be a mechanism common to behavioral addiction and SUDs
Defining Components of addiction
Defining Components of addiction
— Continued engagement in a behavior despite adverse consequences
— Diminished self-control over engagement in the behavior
— Compulsive engagement in the behavior
— An appetitive urge or craving state prior to engaging in the behavior