Understanding The Dynamics of Co-occurring Disorders. Did you ever pull up to a red light and go a little too far into the intersection?

Transcription

1 Understanding The Dynamics of Co-occurring Disorders Joe Garant MA Catholic Human Services Did you ever pull up to a red light and go a little too far into the intersection? So, you put the car in reverse and back up j-u-u-st a little bit. 1

2 And then you forget the car is in reverse? And so you sit there, innocently, waiting for the light to turn green. At this point, folks, you are truly an accident waiting to happen. George Carlin People need not be accidents waiting to happen. 2

3 SERIOUS AND PERSISTENT MENTAL ILLNESS What is it? Who gets it? How is it diagnosed? How is it treated? How do you live with it? WHO GETS SPMI? One in five families in the US are affected by severe mental illness May attack people of any age, race or income level First episode is often associated with a stressful life event WHAT IS IT? A biological brain disorder a VERY physical illness. 3

4 Disease Concept Genetics Biological Predisposition Exposure To a stressful life event (Usually) Time and Severity Different for Everyone TYPES OF PSYCHIATRIC ILLNESSES Bipolar Disorder Depression Schizophrenia Anxiety disorders Organic disorders Personality disorders Developmental disorders Hey I feel better already! 4

5 Role of stress: Vulnerable individual more likely to develop clinical symptoms Intensifies symptoms previously controlled Interferes with response to treatment Severity Scale SEVERE MODERATE MILD MANIC HYPOMANIC EUTHYMIC DYSTHYMIC DEPRESSED Mood 5

6 Depression Prolonged sadness, crying Low energy Changes in sleeping and/or eating Irritability, anger, anxiety Inability to concentrate or make decisions Loss of interest, inability to enjoy Social withdrawal Pain, unexplained physical symptoms Feelings of worthlessness or guilt Thoughts of death and suicide Transient psychotic symptoms DSM IV The Bluebird of Happiness long absent from his life Joe is visited by the Chicken of Depression. Mania Overly happy or irritable mood Decreased need for sleep High energy Impulsiveness, poor judgment Self-important, overly confident Racing thoughts, flight of ideas Reckless behavior, aggressiveness Increased sexual interest/activity Psychotic symptoms DSM IV 6

7 BIPOLAR DISORDER Episodes alternate between mania and depression or may be mixed Long, brief or no periods of wellness between episodes Tendency for increased frequency, duration and intensity over time (esp w/o treatment) More episodes lead to increased treatment resistance DSM IV ANXIETY DISORDERS 7

8 Generalized Anxiety (GAD) is an anxiety disorder that is characterized by excessive, uncontrollable and often irrational worry about everyday things, which is disproportionate to the actual source of worry. This excessive worry often interferes with daily functioning DSM IV Obsessive Compulsive Disorder Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Phobias A phobia is an irrational, intense, persistent fear of certain situations, activities, things, or persons. 8

9 Post Traumatic Stress Disorder The person has been exposed to a traumatic event in which both of the following were present: The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person s response involved intense fear, helplessness, or horror. DSM IV The traumatic event is persistently re-experienced in (or more) of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Recurrent distressing dreams of the event. Acting or feeling as if the traumatic event were recurring. Intense psychological and physiological distress at exposure to internal or external cues. DSM IV WHAT DOES IT MEAN TO BE PSYCHOTIC? A DISTURBANCE OF: Perceptions Thoughts Moods Behavior 9

10 WHAT ARE PSYCHOTIC SYMPTOMS? Impaired ability to Think clearly Perceive things accurately Respond emotionally Communicate effectively Understand reality Behave appropriately DSM IV Auditory Visual Olfactory Olfactory Tactile Hallucinations 10

11 Delusions Paranoid Grandiose Religious Nihilistic one cannot die; reality doesn t exist Somatic Mind control Thought insertion Thought withdrawal Thought broadcasting Ideas of reference DSM IV SCHIZOPHRENIA A brain disorder, often persistent A serious disruption of functioning in all areas of life A chronic psychotic illness 11

12 Why is it when we talk to God, we re said to be praying, but when God talks to us, we re said to be schizophrenic? Anonymous ONSET OF THE ILLNESS Usual before age 25 First episode: association with stressful life events Leaving home New job Marriage Childbirth Menopause FOUR MAIN CLASSES OF PSYCHOTROPIC MEDICATIONS CLASS OF MED TARGET SYMPTOM 1. Mood stabilizers 2. Antipsychotics 3. Antidepressants 4. Anti-anxiety agents 1. Mood swings 2. Psychotic symptoms 3. Depression 4. Anxiety 12

13 Personality Disorders Rigid, inflexible, and maladaptive behavior patterns of sufficient severity to cause significant impairment in functioning or internal stress. If a personality disorder coexists with substance abuse, only the personality disorder will remain during abstinence. DSM IV 13

14 Most Challenging to Treat Antisocial personality disorder, which involves chronic antisocial behavior. Borderline personality disorder, which is characterized by unstable mood and self-image, and unstable intense, interpersonal relationships. Narcissistic personality disorder, which describes a pervasive pattern of grandiosity, lack of empathy. Passive-aggressive personality disorder, which involves covertly hostile but dependent relationships DSM IV Organic Brain Syndrome Any of a group of mental disturbances resulting from temporary or permanent brain dysfunction caused by organic factors such as alcohol, metabolic disorders, and aging. g DSM IV 14

15 Substance Use Disorders Substance Abuse is characterized by problematic use of a substance. Substance dependenced is characterized by tolerance, loss of control, withdrawal and continued use despite good reasons for quitting. DSM IV WHAT IS IT? A biological brain disorder a VERY physical illness. 15

16 Disease Concept Genetics Tolerance, Loss of Control, Withdrawal Exposure You must use to become an addict Time and Severity Different for Everyone Thus. Addicts are born, not made Addiction is a blameless disease Abstinence is the basis for recovery The affected brain takes time to heal Relapse can be devastating 16

17 In simple terms addiction treatment is a decision tree with 2 branches. Man With Complete Mama's Family Video Library Never Again Going On ebay Drunk the onion Substance Abuse and Mental Illness A dual diagnosis or co-occurring disorder occurs when an individual is affected by both chemical dependency and mental illness. Both illnesses may affect a person physically, socially, psychologically, and spiritually. To fully recover, a person needs to address both disorders. 17

18 Co-Occurring Disorders Five to seven million individuals in the US have at least one mental disorder as well as an alcohol or drug use disorder. Individuals with co-occurring occurring disorders have particular difficulty seeking and receiving diagnostic and treatment services, even though, separately, these disorders are as treatable as other chronic illnesses. What Is the Problem? People with mental illnesses, substance use disorders, and co-occurring occurring disorders are significantly overrepresented in the criminal justice system. Typical Location of Services for Different Co-Occurring Populations High III Severity Less severe mental disorder More severe substance abuse Level of care: Substance abuse system IV More severe mental disorder More severe substance abuse Level of care: State hospitals, jails/prisons, emergency rooms, etc. Low Severity I Less severe mental disorder Less severe substance abuse Level of care: Primary health care settings Mental Illness II More severe mental disorder Less severe substance abuse Level of care: Mental health system High Severity 18

19 Characteristics of Co-occurring Disorders (Treatment-related) Poor adherence to medication Decreased likelihood of treatment completion Greater rates of hospitalization More frequent suicidal behavior Difficulties in social functioning Shorter time in remission of symptoms More rapid progression from initial use to substance dependence The Need for Dual Recovery A person with a dual diagnosis may sincerely try to recover from one illness and not acknowledge the other. As a person neglects the mental tl illness, that illness may resurface. This recurrence may in turn lead a person to feel the need to self medicate. What Approaches to Treating Cooccurring Disorders Have Been Tried? Four general approaches have been tried: 1. Not at all referred out to treatment for the other problem or refused care entirely. 2. Serial Treatment one type of disorder treated at a time, in separate settings. 3. Concurrent or Parallel l Treatment treatment for both types of disorder offered at the same time but in separate settings and by separate providers. 4. Integrated Treatment both types of disorder assessed and treated together in specialized settings by providers possessing competency in the treatment of both types of disorder and integrated treatment. 19

20 Why Traditional MH Programs are not Effective for Offenders with CODs Unaddressed and ongoing SA interferes with individuals ability to follow MH treatment recommendations Active substance use interferes with effectiveness of MH treatment (i.e., medications, etc.) MH treatment may not focus on changing substance use and other maladaptive behaviors Why Traditional SA Programs are not Effective for Offenders with CODs Absence of accurate MH diagnosis prevents effective treatment Cognitive impairment detracts from understanding and processing information Confrontational approaches used in SA treatment are not well tolerated Frustration and dropout may result from requirements of abstinence Model Principles (Minkoff) 1. Dual diagnosis is an expectation, not an exception. 2. Empathic relationships + integration and coordination yields treatment success 3. Assign services using the four quadrant model 4. Integrated dual primary treatment of both disorders 5. Match treatment to phase of recovery and stage of change 6. Outcomes must be individualized 20

21 Stages of Change Modifications to Treatment for Co-occurring Disorders At least one year of treatment provided, with potential for ongoing treatment participation More extensive assessment provided Greater emphasis on psycho-educational and supportive approaches Movement through program and tasks is more individualized 21

22 Modifications to Treatment De-stigmatize Mental Illness Treatment groups and other activities are of shorter duration More overlap in activities, pace of treatment activities is slower Information provided gradually, and with significant repetition Modifications to Treatment More individual counseling is provided Deemphasize confrontive approach Higher staff-to-client ratio,,more mental health staff involved in treatment groups Cross-training of all staff Medication Guidelines for CODs from Minkoff, et al (1998) Psychopharmacology for people with co-occurring disorders is best performed in the context of an ongoing, empathic, clinical relationship that emphasizes continuous reevaluation. 22

23 Challenges The most common cause of psychiatric relapse today is the use of substances ( in combination with not taking medication as prescribed) AND The most common cause of a substance use relapse today is untreated psychiatric symptoms. 3 Skills For Professionals What You Have Now. Become adept in spiritual aspects of recovery. Understand the Wrong of the World that people with mental illness and addiction live in (beyond empathy). 23

24 Meaning: The meaning of life is deeply mixed with the philosophical and spiritual conceptions of existence, consciousness, and happiness, and touches on many other issues, such as symbolic meaning, value, purpose, ethics, good and evil, free will, conceptions of God, the existence of God, the soul, and the afterlife. Wikipedia Meaninglessness: Alcoholism and Drug Addiction, ODs, Domestic Violence, Suicide, Murder, Car Crashes, Racism, Infidelity, Sexual abuse, War We came to believe that a power greater than ourselves could return us to sanity. We made a decision to turn our lives over to the care of God as we understood him/her. AA Big Book 24

25 I would entreat professionals not to be devastated by our illness and transmit this hopeless attitude to us. I urge them never to lose hope; for we will not strive if we believe the effort is futile. --Esso Leete, who has had schizophrenia for 20 years There s no success like failure and failure is no success at all. Love Minus Zero/No Limit, Bob Dylan Thanks for listening. 25