W4: Comorbidity and behavioral addictions Flashcards
People who are likely to require a combination of mental health and SUD services
- disabled by comorbid mental health and SUD (integrated approach)
- disabled by MH and affected by SUD (MH service primarily)
- disabled by SUD and affected by MH (SUD service)
- mildly disabled by dual diagnosis (GP)
How many people have comorbid psychiatric conditions
37% of alcohol disorders
53% of other SUD
Consequences and correlates of dual diagnosis
- big rates of treatment noncompliance
- relapse
- disorted perception and cognition
- suicidal ideation
- social exclusion
- homelessness
- agression and injury
- HIV, hepatitis, cardio/liver/gastro diseases
Four explanations for SUD among schizophrenia Gregg
- SUD causes schizophrenia (Cannabis)
- SU as self-medication
- Etiological factors (vulnerability = childhood / bu no genetic evidence)
- Schizophrenia and SUD maintain each other
Treatment issues
- less motivation to change
- harder to engage
- drop out
- slow progress
- psychosis may inhibit process
- narrow coping skills
- idiosyncratic avoidance methods to manage positive symptoms
5 stages of readiness to change Prochaska
- precontemplation
- contemplation
- preparation
- action
- maintenance
Intervensions for Dual Diagnosis
- Motivational Interviewing
- CBT
- Family support
- group interventions
Group interventions
- relapse prevention approaches
- assertive community treatment
- lower intensity treatment
Motivational interviewing
- essential in early stages
- individual might not be aware of problem
- personal choice, responsibility, awareness of risk
- make links between life goals and SUD problems
CBT
- recognize symptoms
- coping with cravings
- healthy alternatives
- normalizing lapses
- plan for relapse
- cognitive restructuring to counteract positive beliefs of SUD
Relapse prevention approaches
- tailored to each participant abilities
- traditional 12 step approach
- uneffective for dual diagnosis
Assertive community treatment
- structured health care service
- conventional model of case management to needs of cohort
- better outcomes on SU and quality of life, but equal on other
Lower intensity treatment
- freedom to leave facility
- community based daily attendance
- less responsibility for peers
- direct staff involvement
- less intense therapy
- better outcomes at 1-2 y follow up
Treatments that work for dually diagnosed
- effective psychiatric
- reducing SUD treatments
People with schizophrenia and SUD can benefit from
CBT + MI
Women with SUD, PTSD and depression can benefit from
CBT
Tiet and Mausbach that evidence of integrated treatment having superior outcome is
weak
Broad service models of potential treatment
- sequential (one condition, then another)
- parallel (by isolated providers)
- integrated (by same team)
Initial focus on treatment plan
- therapeutic alliance
- MI
- relapse prevention
- case management
Adherence can be facilitated by
atypical antipsychotic medications
Behavioural addictions
Grant
diminished control as core
DSM-4 impulse control disorders
Similarities of behavioural addictions and SUD
- failure to resit impulse and drive to harm person or others
- repetitive engagement
- less functioning in other domains
- onset in teen or young adult
- chronic relapse paterns
- ego syntonic nature (except OCD which is dystonic) => with time become more dystonic
- dysphoric state while abstinence
- tolerance
- no reports on serious withdrawal states
types of behavioural addictions
- pathological gambling
- kleptomania
- skin picking
- compulsive sexual behaviour
- internet addiction
- compulsive buying
Personality attributes of behavioural addictions
- high scores on impulsivity and sensation seeking, compulsivity
- low scores of harm avoidance
Personality of internet addictions
- psychoticism
- interpersonal conflict
- self directness
Personality of OCD
- high harm avoidance
- low on impulsivity
Highest rate of comorbidity of SUD and BA
gambling
alcohol
antisocial personalities
Study on neurocognition of gamblers and alcoholics
- diminished inhibitions, cognitive flexibility and planning tasks
- no difference in executive functioning
High levels of impulsivity and sensation seeking correlate
with low CSF-5-HIAA metabolite
Urge driven disorders are receiving incoming reward input from
ventral tegmental area
nucleus accumbens
OFC circuit
Antagonists of D2/D3 receptors enhance
gambling related motivations
Twin studies one co-occurence of gambling and alcohol use show that
genes influence both disorders
higher frequencies of serotonin transporter gene 55HTTPLR
higher harm avoidance => internet users
Behavioural addictions and dopamine
- learning, motivation, reward
- DA release => adaptive and maladaptive decision making
- internet addiction => reduced D2/D3 activity in striatum
DA receptor availability is negatively correlated with (a) and positively correlated with (b)
a- mood related impulsivity within striatum
b-gamling severity within dorsal striatum
In Parkinsons patients, DA agonist medication are associated eith
-gambling and other B.A
Serotonin and BA
- emotions, motivation, inhibition, control
- dysregulation => mediate behavioural inhibition and impulsivity in gambling
Gambling depicts dysregulations is
HPA axis
increases level of noradrenergic moieties
Better than placebo in treatment of gambling are
opioid antagonists
Simulated gambling and decision making task are linked to
vmPFC
mesolimbic reward pathway from VTA to NA
smaller amygdala and hippocampal volumes
3 phases of treatment for BA
- detoxication
- recovery (sustained motivation, strategies of craving)
- relapse prevention
Pharmacological interventions of BA
- opiod receptor antagonist (most evidence)
- SSRIs (mixed)
- glutamatergic (small)
There is a high genetic effect on
the latent externalising propensity
Chromosome 7 is offering
risk for externalising outcomes
Single nucleotide polymorphism in CHRM2 gene are associated with
- risk of alcohol dependence
- comorbid alcohol and drug
Valiadated markers for mental disorders
- PFC: disinhibition
- orbitomedial PFC: cognitive over emotional
- P300 evoked potential: reduced in externalising disorders and SUD
The independence of factors in the hierarchical models states for
multiple underlying pathways can lead to same clinical outcomes
