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Title: Co-occurring Disorders The Mix of Meds and Therapy

Co-occurring DisordersThe Mix of Meds and Therapy
  • Illinois Department of Human Services
  • Cross Divisional Training
  • February 19, 2008
  • Seth Eisenberg MD

About Me
  • Psychiatric Residency in San Francisco
  • Child Psychiatry--Adolescent CD
  • Community Mental Health, Marin County Jail--
  • HawaiiAdol. CD, private sector (ice)
  • Charter Hospital NW Indiana (PG),
  • Interventions, WTC, MPG, CAP, TASC
  • DASA medical director
  • Northwesternfellowship, in-patient

Co-occurring DisordersThe Mix of Meds and
TherapyAgenda Topics
  • Working with CODAttitudes of Clinicians
  • Meds for Anxiety and Mood Disorders
  • Medication TreatmentGeneral Principles
  • Integrated Tx for Anxiety and Alcohol
  • Talking to Patients about Medications
  • Skeptical Attunement

DUAL DIAGNOSIS Complications of Comorbidity
  • Increased Severity of Symptoms
  • Increased Psychiatric Hospitalization
  • Increased Use of Emergency Services
  • Increased Violent and Suicidal Behavior

DUAL DIAGNOSIS Poor Psychosocial Adjustment
  • Increased Homelessness
  • Increased Unemployment
  • Increased Vocational Disability
  • Lack of Social Support Systems
  • Earlier Age of Onset
  • Treatment Chronicity

Attitudes and Values for Clinicians
  • Patience, perseverance, and therapeutic optimism
  • Ability to employ diverse theories, concepts,
    models and methods
  • Flexibility of approach
  • Cultural competence
  • Belief that all individuals have strengths and
    are capable of growth and development

Six Guiding Principles in Treating Clients with
  • Employ a recover perspective
  • Adopt a multi-problem viewpoint
  • Develop a phased approach to treatment
  • Address specific real-life problems early in
  • Plan for the clients cognitive and functional
  • Use support systems to maintain and extend
    treatment effectiveness

Recovery Perspective
  • Assess clients stage of change
  • Treatment stage (or expectations) should be
    consistent with stage of change
  • Use client empowerment to enhance motivation
  • Foster continuous support
  • Provide continuity of treatment
  • Recognize that recovery is a long-term process
    and support small gains

Therapeutic Alliance
  • Demonstrate understanding and acceptance
  • Help client clarify nature of the difficulty
  • Indicate you and client will be working together
  • You will be helping client help themselves
  • Express empathy and willingness to listen to the
    clients view of the problem
  • Assist client to solve some external problems
    directly and immediately

Using an Empathic Style
  • An Empathic Style
  • Communicates respect for and acceptance of
    clients and their feelings
  • Encourages a nonjudgmental, collaborative
  • Allows the clinician to be a supportive and
    knowledgeable consultant

Using an Empathic Style
  • An Empathic Style
  • Compliments and reinforces the client whenever
  • Listens rather than tells
  • Gently persuades, with the understanding that the
    decision to change is the clients
  • Provides support throughout the recovery process

Successful Therapeutic Relationships
  • Use a therapeutic alliance to engage
  • Maintain a recovery perspective
  • Use supportive and empathic counseling
  • Manage countertransference
  • Monitor psychiatric and SUD symptoms
  • Employ culturally appropriate methods
  • Increase structure and support

Anxiety Disorders and SUDPrevalence
  • 18 with SUD--at least one anxiety disorder
  • 15 with AD had at least one SUD
  • Treatment seekers for AUD23-69 w AD
  • Treatment seekers for SUD50 w AD
  • Treatment seekers for AD12 w AUD
  • Treatment seekers for AD7 w SUD
  • Clear need for cross discipline screen,
    assessment and treatment

Anxiety Disorders and SUDExplanatory Models
  • Secondary substance use model
  • Self medication substance interacts with
    psychiatric disturbance to make use compelling in
    susceptible individuals
  • Ongoing use leads to development of SUD
  • Secondary psychopathology modelSUD leads to the
    development of psychiatric d/o
  • Substance use may sensitize neurobiological
    stress systems and lead to higher level of
    vulnerability to PTSD systems after trauma

Anxiety Disorders and SUDExplanatory Models
  • Common factor model
  • underlying genetic or physiologic liability
  • anxiety sensitivity tendency to interpret
    feelings of anxiety as dangerous
  • Bi-directional model
  • Both the SUD and anxiety disorder play a role in
    either developing or maintaining each other
  • Social phobic uses alcohol, develops more
    problems, increased anxiety and more ETOH

Anxiety Disorders and SUDExplanatory Models
  • Self Medication Hypothesis
  • People with anxiety and SUD would report that
    they use substances to manage anxiety
  • People with more severe anxiety would be at
    increased risk for SUD
  • Anxiety would precede substance use
  • Substances used by people with anxiety and SUD
    would be anxiolytic

Panic Attack
  • Palpitations, pounding, chest pain/discomfort
  • Sweating
  • Trembling or shaking
  • SOB
  • Feeling of choking
  • Nausea or abdominal distress
  • Dizzy, unsteady, lightheaded or faint
  • Derealization, depersonalization
  • Fear of losing control, going crazy, dying

Panic Disorder
The presence of recurrent, unexpected panic
attacks followed by persistent concern about
having another panic attack. (DSM IV) ? 1.5 -
3.5 Lifetime prevalence Panic attacks may
be induced by substance use ? With or without
agoraphobia ? TCAs and SSRIs Block panic
attacks Start with low doses ? Latency of
onset - use of benzodiazepines
  • Anxiety about being in places or situations from
    which escape might be difficult (or embarrassing)
    in the event of a panic attack
  • The situations are avoided or are endured with
    marked distress
  • Anxiety or phobic avoidance is not better
    accounted for by another mental disorder

Anxiety Disorders and SUDMedication Treatment
  • Panic Disorder (5-42 in AUD, 7-13 in MMT)
  • SSRI, TCA, MAOI, benzodiazepines all effective
    (not studied in COD populations)
  • May have initial activation with SSRI and TCA
    that could increase risk of relapseuse low dose
  • Latency of onset of effect, 2-6 weeks
  • SSRIsno abuse potential, safe, generally well
    tolerated, may help with ETOH

Anxiety Disorders and SUDMedication Treatment
  • Benzos usually avoided in SUD populations (but
    not an absolute contraindication)
  • Panic disorder can also be treated with
    anticonvulsants (valproate or carbamazepine) and
    Panic with stimulant abuse may respond to these
    agents due to neuronal sensitization and limbic
  • TCAs carry risk of lower seizure threshold and
    interactions with ETOH, depressants and stimulants

Social Phobia
  • Marked and persistent fear of social or
    performance situations, possible scrutiny by
    others or may act in a way that will be
    embarrassing or humiliating
  • Exposure to feared social situation provokes
    anxiety (or may have panic attack)
  • Person recognizes that the fear is excessive
  • Feared situations are avoided or endured
  • Avoidance, anxious anticipation or distress
    interferes with functioning

Anxiety Disorders and SUDMedication Treatment
  • Social Anxiety Disorder (8-56 in AUD, 14 in
    cocaine, 6 in MMT)
  • In most cases SAD precedes AUD so a period of
    abstinence not so important
  • Early identification important with COD as SAD
    may interfere with SUD treatment
  • SSRI have FDA indication (paroxetine) and may
    also reduce alcohol use
  • Venlafaxine and gabapentin

Generalized Anxiety Disorder
  • Excessive anxiety and worry (apprehensive
    expectation) about number of events occurring
    more days than not
  • Difficult to control the worry
  • Associated with three or more frequently present
  • Restlessness or feeling keyed up, on edge
  • Easily fatigued,
  • Irritability
  • difficulty concentrating or mind going blank
  • Muscle tension
  • Sleep disturbance

Anxiety Disorders and SUDMedication Treatment
  • Generalized Anxiety Disorder (8-52 in AUD, 21
    in MMT, 8 in cocaine)
  • Diagnostic difficultiesoverlap with symptoms of
    acute intoxication with stimulants and withdrawal
    from alcohol and sedatives (and anxiety in early
  • SSRI, TCA, venlafaxine, anticonvulsants
  • Use of benzodiazepines is controversial
  • Buspirone may be effective

Mood Disorders
  • Depressive Disorders
  • Major Depressive Disorder
  • Dysthymic Disorder
  • BiPolar Disorders
  • Bipolar I
  • Bipolar II
  • Cyclothymic Disorder
  • Substance Induced Mood Disorder

Affective Illness and CD
1. Convincing history of affective disorder
previously diagnosed, ideally during abstinence,
with historical indications of expected
medication response if medicated. 2. Depression
is a normal feeling state in early
sobriety. 3. Mania must be distinguished from
anxiety and chronic ADHD.
Affective Illness and CD (continued)
4. Positive family history is suggestive. 5. Seek
historical evidence of episodic mood alterations
that last for weeks/months and are independent of
Depressive Disorders and CD
  • 5 - 25 up to 90
  • Varied time for improvement based on substance
  • Depression part of recovery process
  • Abuse of TCAs in methadone clinics, elevated
    blood levels
  • Activating effect, cardiotoxicity
  • SSRIs better tolerated, safer, decreased drinking

Medications for Bipolar and SUD
  • Bipolar with SUD56 (ECA), most common Axis I
  • SUD assoc. w poor prognosis in Bipolar
  • More hospitalizations for affective episodes
  • Affective sx earlier in life
  • More depressive or mixed episodes
  • COD w increased time to med treatment
  • Increased risk for antidepressant induced mania

Medications for Bipolar and SUD
  • Lithium may be less effective in COD
  • May be useful in adolescents with COD
  • More responsive to anticonvulsants
  • Kindlingneuronal sensitization in alcohol
    withdrawal and cocaine intoxication
  • Valproate (may also decreased drinking)
  • Carbamazepine (helpful with cocaine)
  • Generally safemonitor liver and blood count
  • topiramate helpful in alcohol dependence

Medications for Bipolar and SUD
  • lamotraginehelped with cocaine
  • Gabapentinmay help with alcohol/anxiety
  • Atypical antipsychotics
  • Seroquelmood, alcohol, anxiety
  • others

Ask the Doc
Medication Treatment of Psychiatric and Substance
Use Disorders
  • Psychotherapeutic Medications What Every
    Counselor Should Know
  • Mid-America Addictions Technology Transfer Center

Medication TreatmentGeneral Principles
  • Pharmacologic effects
  • Therapeuticindicated purpose and desired outcome
  • Detrimentalunwanted side effects (may interfere
    with adherence), potential for abuse and
  • Need a balance between therapeutic and

Medication TreatmentGeneral Principles
  • Psychoactive Potential Ability of some
    medications to cause distinct change in mood or
    thought and psychomotor effects
  • Stimulation, sedation, euphoria
  • Delusions, hallucinations, illusions
  • Motor acceleration or retardation
  • All drugs of abuse are psychoactive

Medication TreatmentGeneral Principles
  • Many medications are non-psychoactive (except for
    mild side effects including sedation or
  • Not considered euphorigenic( although can be
    misused and abused)
  • Psychoactive drugs considered high risk for abuse
    and addiction
  • Some psychoactive meds have less addiction
    potential (old antihistimines)

Medication TreatmentGeneral Principles
  • Positive reinforcementincrease the likelihood of
    repeated use
  • Amplification of positive symptoms or states
  • Removal of negative symptoms or conditions
  • Faster reinforcement, more prone to misuse
  • Tolerance and Withdrawal
  • Higher risk for abuse and addiction
  • More concerns when prescribing to high-risk

Medication TreatmentStepwise Treatment Model
  • Risks/benefits analysis (risk of medication, risk
    of untreated condition, interactions, potential
    for therapeutic benefits)
  • Early and aggressive treatment of severe
    psychiatric problems
  • Start with more conservative approach with high
    risk patients and less severe conditions

Medication TreatmentStepwise Treatment Model
  • High risk patients with anxiety disorder
  • Non-pharmacologic approaches when possible
  • Non-psychoactive medications added next as
    adjunctive treatment
  • Psychoactive medications when other treatments

Medication TreatmentStepwise Treatment Model
  • Non-pharmacologic approaches
  • Psychotherapy, cognitive and behavioral tx,
    stress management skills, medication, exercise
    biofeedback, acupuncture, education, etc
  • Use meds with low abuse potential
  • Conservative approach not the same as
  • Different treatments should be complementary, not

Which to treat first Comorbid anxiety or alcohol
  • Current Psychiatry
  • Vol. 6 No.8/Aug 2007
  • Kushner, et al.

Comorbid Anxiety and Alcohol Which Comes First?
  • Generalized Anxiety Disorder (8-52 in AUD, 21
    in MMT, 8 in cocaine)
  • Diagnostic difficultiesoverlap with symptoms of
    acute intoxication with stimulants and withdrawal
    from alcohol and sedatives (and anxiety in early
  • SSRI, TCA, venlafaxine, anticonvulsants
  • Use of benzodiazepines is controversial
  • Buspirone may be effective

Comorbid Anxiety and Alcohol Which Comes First?
  • Risk of getting new ETOH Dep as a Jr/Sr more that
    tripled among students with anxiety dx as a
  • Students with ETOH Dep as freshman were 4xmore
    likely to dev. an anxiety d/o (6yrs)
  • So having either an anxiety or ETOH d/o earlier
    in life apears to increase the probability of
    developing the other later

Comorbid Anxiety and Alcohol Treatment Approaches
  • Serial (sequential) approachtreatment comorbid
    disorders one at a time
  • Parallel approachproviding simultaneous but
    separate treatments for each comorbidity
  • Integrated approachproviding one treatment that
    focuses on both comorbid disorders, especially as
    they interact with one another
  • Tx determined by clinical and resources

Comorbid Anxiety and Alcohol Treatment Approaches
  • Serial Treatmenttreat disorder one at a time
  • May help empirically evaluate whether the
    untreated condition is resolved by treating other
  • Allows use of established treatment resources
  • Initially untreated comorbid disorder could
    undermine resolution of the treated disorder.
  • Not always clear which disorder to treat
    firstmay depend on presenting symptom
  • Tx with meds for anxiety and then address ETOH
    with brief intervention

Comorbid Anxiety and Alcohol Treatment Approaches
  • Parallel Treatmentsimultaneous/separate
  • may be less common in MH settings
  • Requires coordination of clinicians, tx
    strategies, times, locations
  • Impact of other disorder not appreciated
  • MH vs SUD treatment programs may have conflicting

Comorbid Anxiety and Alcohol Treatment Approaches
  • Integrated Treatmentone treatment plan (or one
    tx) for both disorders (not many)
  • CBT-based integrated approach
  • Psychoeducation
  • Cognitive restructuring
  • Cue exposure

Comorbid Anxiety and Alcohol CBT-based
integrated approach
  • Psychoeducationexplain biopsychosocial model of
    anxiety/alcohol disorders
  • Basic epidemiology
  • Negative interactions between the two
  • Introduce role of cognitions, thoughts, beliefs
    and expectations
  • Teach diaphragmatic breathing to reduce

Comorbid Anxiety and Alcohol CBT-based
integrated approach
  • Cognitive restructuring(req.CBT skills)
  • Thinking patterns that contribute to initiating
    and maintaining anxiety and panic
  • Recognized and restructure thinking that promotes
    alcohol use to cope w anxiety

Comorbid Anxiety and Alcohol CBT-based
integrated approach
  • Cue exposuretherapist guided exposure to fear
    provoking situations and sensations to decouple
    from anxiety and catastrophe
  • Helps with reality testing
  • Practice for anxiety management skills
  • Enhance self-efficacy

Comorbid Anxiety and Alcohol CBT-based
integrated approach
  • Exposures (imaginal and in vivo) expanded to
    include alcoholrelevant cues assoc. with anxiety
    states to decouple self-medication and practice
    other coping skills
  • CONCLUSION Effects of Integrated CBT TX for
    comorbid panic and alcohol disorders was more
    effective for patients with the strongest for
    patients with strongest expectations that alcohol
    helps control their anxiety

Talking to Patients about Medications
  • Make an inquiry every few sessions
  • Are their Psych meds. Helpful? How?
  • How many doses or how often do you miss?
  • Acknowledge that taking pills everyday is a
    hassle and everybody misses sometimes
  • Did they feel or act different? Or use?
  • Explore connections of MH, meds, use
  • Forget? Or choose not to take it.

Medication AdherenceComorbid SUD a Risk Factor
for Non-adherence
  • May have conflicted feelings and attitudes about
  • Meds may be sometimes discouraged or thought to
    be un-needed
  • See it as a sign of weakness
  • May stop meds during relapse
  • May misused meds

Talking to Patients about Medications
  • Problem solve strategies to not forget
  • Use a pill box, help set it up
  • Keep it where it cannot be missed or avoided
  • Link med taking with some daily activity
  • Use an alarm clock set for the time to take
  • Ask someone to help them take meds

Talking to Patients about Medications
  • Some patients may choose not to take meds
  • They have a right to make that choice
  • Owe it to themselves to make sure their important
    health decision is well thought out
  • Explore-- I just dont like pills (or meds).
  • Elicit a reasonnever needed it, cured now, dont
    believe in it, means Im crazy, side effects,
    afraid, shame, cost, interpersonal, want to be in
    control, do it on my own, cant use
  • Motivational Interviewing

Psychotherapy for Patients with Co-occurring
  • Skeptical Attunement
  • Modifying Psychodynamic Technique for Substance
    Abuse Treatment
  • Karen Frieder, PhD
  • Roy Futterman, PhD
  • Susan Silverman, PhD

Psychotherapy for DDX Skeptical Attunement
  • Skeptical attunement is the use of healthy
    skepticism as a means of confronting the patient
    in a way that is experienced as empathic
    attunement, leading to more meaningful work.

Psychotherapy for DDX Skeptical Attunement
  • Psychodynamic technique can fill a gap in current
    addiction treatment by addressing the emotional
    discomfort and disconnection that underlies a
    great deal of substance use.
  • Model of psychodynamic work that will help to
    focus on patients emotional lives, their
    specific substance abuse behaviors and will make
    explicit the connections
  • Help patients gain control over their substance
    use as well as their emotional lives.

Psychotherapy for DDX Skeptical Attunement
  • Historical Context
  • Addiction a symptom of underlying psychopathology
  • Standard analytic technique without directly
    addressing substance use
  • Others felt Tx not appropriate until sober or
    that patients were unanalyzable

Psychotherapy for DDX Skeptical Attunement
  • Historical Context
  • AA felt psychology had little to offer
  • 12 Step, TCs, Self help, abstinence
  • May have been anti-psychiatric care
  • Patients in denial, not ready, havent hit bottom

Psychotherapy for DDX Skeptical Attunement
  • Recent advances in psychotherapy for addiction
  • Relapse Prevention
  • Harm Reduction
  • Motivational Interviewing

Psychotherapy for DDX Skeptical Attunement
  • Relapse Prevention
  • Assumes relapse a natural and predictable part of
    the recovery process
  • Discuss and learn from each relapse to prevent
    future relapses
  • CBT Function analysis
  • Relapse is not random and patients can learn the

Psychotherapy for DDX Skeptical Attunement
  • Harm Reduction
  • Patients accepted into treatment with various
    levels of substance use
  • Abstinence not a mandated goal or prerequisite
  • Practitioner seeks to reduce the negative impact
    of substance use on patients
  • Similar to psychiatric treatment in that patients
    are treated in individualized manner

Psychotherapy for DDX Skeptical Attunement
  • Motivational Interviewing
  • Stages of change, change is a process
  • Different interventions for different stages
  • Patients ambivalence about use is normal
  • Enhance discrepancy
  • Therapist role to increase client motivation
  • Join with clients to gain insight and
    understanding to gain more control

Psychotherapy for DDX Skeptical Attunement
  • Self Medication Theory Patients use drugs to
    self-medicate intolerable emotions
  • Undiagnosed, untreated psychiatric illness
  • Grief and trauma
  • Difficulty regulating emotions
  • Disconnected from and unaware of emotions
  • Poor interpersonal skills and relationships

Psychotherapy for DDX Skeptical Attunement
  • Modified Psychodynamic Technique Goal to
    increase awareness, make the unconscious
    conscious and connect emotional life to using
  • Clinician more active and symptom focused
  • Asking about use, risky situations, triggers
  • Use of psychoeducation
  • More transparent and genuine
  • Discuss countertransference and skepticism

Psychotherapy for DDX Skeptical Attunement
  • Working with Defenses
  • Main defense is to use. Also denial,
    displacement, dissociation, intellectualization
  • Keeping on the run physically, interpersonally
  • Defense against what?
  • relate defenses to thoughts and emotions which
    lead to urges and relapse
  • Talking about it (to gain insight) will lead to

Psychotherapy for DDX Skeptical Attunement
  • Talking about Cravings and Triggers
  • Client reluctance to disclose illegal, cause
    them trouble, secret, weakness, guilty, shame,
    other associated bad behaviors
  • Therapist non-judgmental and more active
  • Deny cravings
  • Mistake withdrawal for cravings and cravings for

Psychotherapy for DDX Skeptical Attunement
  • Talking about Cravings and Triggers
  • Behavioral patterns to cravingsPeople places and
  • Stress and emotions (negative and positive)
  • Mindfulness to physical and emotional self
  • Connection to behaviorbefore and after
  • Craving itself is short lived
  • Working with dreams

Psychotherapy for DDX Skeptical Attunement
  • Talking about Cravings and Triggers
  • Recognizing and labeling to stop a relapse
  • Sensitivity to transitions
  • Pleasures, meanings and role of use (further
    insight into triggers, losses and needs)
  • Fulfillment of rituals and excitement
  • Sexuality and intimacy

Psychotherapy for DDX Skeptical Attunement
  • Skeptical Attunement Any break from the norm
    should be assumed by the clinician to be related
    to relapsethere may be numerous signs and
  • clinician may point out changes and predict a
    relapse (if before the relapse)
  • ask pointed questions about whats happening
  • reference observations or recent behavior

Psychotherapy for DDX Skeptical Attunement
  • Skeptical Attunement
  • Contrast current to more usual behavior
  • Matter of fact attitude, assumption of relapse
  • Straightforward but not accusatory
  • May make disclosure more easy (or patient can
    refute it)
  • Clients experience this as attunement dont want
    a clinician who is overly trusting and naïve
  • Not attacking, not ignoring, tuned in
  • May help with clinician countertransference

Psychotherapy for DDX Skeptical Attunement
  • Countertransference
  • Anticipate being lied to, manipulated, misused
  • (attenuated with skeptical attunement and
    directly addressing behaviors and observations)
  • Ineffectual, suspicious punitive interrogator
  • (awareness of need for and origins of
  • Hurt, disappointed and angry with relapse
  • (attenuated with harm reduction and relapse prev)
  • Need to be seen as street savey (reflect w truth)
  • Are you in recovery? (explore but answer)