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The Victorian State-wide Problem Gambling & Mental Health Program (PG&MHP) Ph: 9076 4700 Fax: 9076 4788 Level 2,435 Malvern Road, South Yarra, Vic 3141 Co-morbidity in Problem Gambling: Differential Diagnosis & Treatment implications Jenny Makros Clinical Psychologist Vicky Northe Social Worker Objectives To become familiar with: • Prevelance of comorbid gambing and mental health disorder • Assessing for comorbit conditions • Differential diagnosis – Borderline Personalilty Disorder V Bipolar Affective Disorder – Diagnoses based on mood episodes, impulsivity, and longitudinal course of borderline personality disorder and bipolar disorder – Treatment implications - pharmacological and psychosocial interventions Problem Gambling and Mental Health Disorders Prevalence data • 41-60% Anxiety Disorder – • 37-50% Depression: (past year) – • The Victorian Department of Justice (2009); Volberg et al (2006) 6-12% Bipolar Affective Disorder • • Kessler et al (2008); Petry et al (2005); The Victorian Department of Justice (2009) McIntyre et al (2007); Kennedy et al (2010) 73% alcohol use disorder Petry et al (2005). • 61% personality disorder Petry et al (2005) – General population • 6.5% (AUS) Jackson & Burgers (2000) • 9.1% (US) Lenzenweger et al (2007). • 4.4% (UK) Coid et al (2006) Prevalence of Mental Disorders in Australian adults (% in any one year) 25 22 18 20 15 11 18 20 14 10 7 6 5 5 Males 7 3 5 Females Persons 0 Anxiety Disorders Affective Disorders Substance Use Dis. Total any Disorders 2007 National Survey of Mental Health and Wellbeing conducted by the Australian Bureau of Statistics. Assessing for Co-morbidity • Theoretical model • System of classification • Assessment process Early contact with services Gamblers will often present for non-gambling specific symptoms: – – – – – – – – – – – – – Low mood Anhedonia Sleep difficulties Sense of worthlessness / hopelessness Suicidal ideation Tension Restricted breathing Heart palpitations Headaches Gastrointestinal problems Irritability, agitation & anger Alcohol or drug problems Personal / relationship / family / employment problems Ecological Factors Increased Availability & Accessibility Classical & Operant Conditioning •Arousal/Excitement •Subjective Excitement & Physiological Arousal •Cognitive Schemas •Irrational Beliefs, Illusion of Control, Biased Evaluation, Gambler’s Fallacy Gambling Pathway 1 No psychopathology prior to gambling difficulties Habituation Pattern of Habitual Gambling Established Chasing Chasing wins, losses; Losing more than expected Gambling related mental health issues Problem Gambling Blaszczynski, A., & Nower, L. (2002). Ecological Factors Increased Availability & Accessibility Classical & Operant Conditioning •Arousal/Excitement •Subjective Excitement & Physiological Arousal •Cognitive Schemas •Irrational Beliefs, Illusion of Control, Biased Evaluation, Gambler’s Fallacy Habituation Pattern of Habitual Gambling Established Chasing Emotional Vulnerability Child Disturbance Personality Risk Taking Poor coping/Problem Solving Boredom Proneness Depression Anxiety Life Stresses Substance Use Biological Vulnerability Biochemical Serotonergic Noradrenergic Dopaminergic Cortical EEG Differentials Chasing wins, losses; Losing more than expected Gambling Pathway 2 Problem Gambling The emotionally vulnerable gambler Blaszczynski, A., & Nower, L. (2002). Ecological Factors Increased Availability & Accessibility Classical & Operant Conditioning •Arousal/Excitement •Subjective Excitement & Physiological Arousal •Cognitive Schemas •Irrational Beliefs, Illusion of Control, Biased Evaluation, Gambler’s Fallacy Habituation Pattern of Habitual Gambling Established Chasing Chasing wins, losses; Losing more than expected Problem Gambling Pathway 3 Emotional Vulnerability Child Disturbance Personality Risk Taking Poor coping/Problem Solving Boredom Proneness Depression Anxiety Life Stresses Substance Use Biological Vulnerability Biochemical Serotonergic Noradrenergic Dopaminergic Cortical EEG Differentials Impulsive Traits Neuropsychological Attention deficits Hyperactivity Personality disorders Blaszczynski, A., & Nower, L. (2002). Classification of co-morbid conditions Factors that may affect the diagnosis, treatment, and prognosis of mental disorders Acute symptom clusters Conditions requiring immediate attention e.g. problem gambling; major depression; anxiety; schizophrenia, bipolar Pervasive chronic symptoms Personality disorders Developmental disorders May not require immediate attention but may complicate treatment Medical or neurological conditions Conditions that may influence a psychiatric problem. E.g. diabetes might cause extreme fatigue which may lead to a depressive episode. Recent psychosocial stressors Psychosocial and Environmental stressors e.g. a death of a loved one, divorce, losing a job The person’s general level of functioning – – – – The Global Assessment of Functioning (GAF) Scale (0-100 rating). Score 1 - 30 This client is a candidate for inpatient care Score 31 - 69 This client is a candidate for outpatient care - mental health / counselling services / private Score 70 - > In most cases, medical or psychosocial interventions are not necessary Systematic Assessment of the Problem • Presenting Problem • • • • • Current symptomatology (clusters of symptoms) Stressors Risk Current treatment & services Mental State Examination • Bio-psycho-social Hx • • • • • Symptom history & other disorders Treatment History Developmental, family, & work history Drug & alcohol History Health history • Screening questionnaires & scales: e.g. • DASS – Depression, Anxiety and Stress Scale • Canadian Problem Gambling Index • Work & Social Adjustment Scale • Global Assessment of Functioning (GAF) scale Differential diagnosis -Clinical Disorders • • • • • • • • • • • • • • • • Adjustment Disorders x5 Anxiety Disorders x14 Cognitive Disorders x 3 Dissociative Disorders x 5 Eating Disorders x 3 Factitious Disorders x 3 Impulse-Control Disorders (Not Classified Elsewhere) x 6 Mental Disorders Due to a General Medical Condition x2 Mood Disorders x11 Schizophrenia and other Psychotic Disorders x 12 (including subtypes) Sexual and Gender Identity Disorders x 9 Sexual Dysfunction x 10 Sexual Pain Disorders x 2 Sleep Disorders x 11 Somatoform Disorders x 6 Substance-Related and Addictive Disorders x 16 e.g. Gambling Disorder • Personality Disorders x 10 Differential diagnosis -Clinical Disorders • • • • • • • • • • • • • • • • • Adjustment Disorders x5 Anxiety Disorders x14 Cognitive Disorders x 3 Dissociative Disorders x 5 Eating Disorders x 3 Factitious Disorders x 3 Impulse-Control Disorders (Not Classified Elsewhere) x 6 Mental Disorders Due to a General Medical Condition x2 Mood Disorders x11 Schizophrenia and other Psychotic Disorders x 12 (including subtypes) Sexual and Gender Identity Disorders x 9 Sexual Dysfunction x 10 Sexual Pain Disorders x 2 Sleep Disorders x 11 Somatoform Disorders x 6 Substance-Related and Addictive Disorders x 16 e.g. Gambling Disorder Personality Disorders x 10 Differential Diagnosis -an exampleBipolar Disorder or Borderline Personality Disorder? Distinguishing features, Treatment Implications & Prognosis John • John is a 53-year-old, never-married man with a 25 year history of gambling on the pokies and TAB. He has a 20 year history of heavy alcohol use. John describes current anxiety, irritability and depression. While he identified gambling and drinking as a problem, in session he is often preoccupied with his partner’s fidelity and whereabouts. He had rapid mood shifts in session, particularly when the discussion centered on his current romantic relationship. • John first presented to Gamblers Help services three years ago when he went to see his GP for low mood and admitted to a history of gambling. His attendance at GH has been inconsistent and his response to treatment poor. John has disengaged from the service on a number of occasions, often returning after or during periods of crisis during which he describes engaging in a number of impulsive behaviours, including gambling, sexual promiscuity and drinking. These behaviours were often triggered by interpersonal conflict. • John denied any current or past suicidal or homicidal ideation but endorsed a history of “mood swings.” John described brief ‘high’ periods of elation though his elevated mood would often be centered on feelings of hostility and anger. Manic mood and behaviour Euphoria Negative mood and behaviour Grandiosity Depression Pressured speech Anxiety Impulsivity Irritability Excessive libido Hostility Recklessness Social intrusiveness Diminished need for sleep Bipolar Disorder Violence or suicide Cognitive symptoms Psychotic symptoms Delusions Halllucinations Formal thought disorder Racing thoughts Distractibility Disorganization inattentiveness Bipolar Disorders • Bipolar 1 Disorder: – one or more manic or mixed episodes usually accompanied by major depressive episodes • Bipolar 2 Disorder: – one or more depressive episodes accompanied by at least one hypomanic episode • Cyclothymic Disorder: – at least 2 years of numerous periods of hypomanic and depressive symptoms that do not meet threshold for manic or depressive episodes Borderline Personality Disorder A pervasive pattern of unstable interpersonal relationships, self image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts Five (or more) of the following: 1. frantic efforts to avoid abandonment. 2. Unstable and intense interpersonal relationships 3. identity disturbance: Unstable self-image or sense of self. 4. impulsivity (e.g., spending, sex, substance abuse, reckless driving, binge eating). 5. recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour 6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. chronic feelings of emptiness 8. Inappropriate and frequent, intense anger or difficulty controlling anger 9. transient, stress-related paranoid ideation or severe dissociative symptoms Borderline Personality Disorder & False positives Bipolar Disorder 17% Depression 13% False positive diagnosis Borderline Personality Disorder 26% Eating disorders Anxiety disorders 1% 10% Meyerson et al. (2009) American Psychiatric Association preliminary study Overlapping symptom clusters Irritability Bipolar affective instability impulsivity BPD Distinguishing features • Quality of mood episodes • Types of impulsivity • Longitudinal course Irritability Bipolar affective instability impulsivity BPD Mood episodes: phenomenology BPD Mood swings Bipolar Mood Swings Triggered by interpersonal stressors or perceived stresors Mood swings are more spontaneous Usually negative affect Transient (hours or day) Highly dependent on the environment Affective instability is part of a characteristic pattern of emotional responding More extended periods of elation Of longer duration (especially for bipolar I; 1 week+) Less dependent on the environment Clearer intervals of acute episodes and symptom-free periods Mood episodes: Type of emotion BPD Swing from euthymia to anger Bipolar euthymia is infrequent Depression to elation (bipolar I) Shifts triggered by interpersonal stressors (rejection or perceived abandonment) Affective shifts are from euthymia to elation (Bipolar II) Distinct periods of euthymia Interpersonal triggers are less prevalent in bipolar disorder Mood episodes: Mania BPD disturbed relatedness behavioural dysregulation affective dysregulation Bipolar psychic and motor acceleration psychosis irritability Mood episodes: Differentiating BPD from Bipolar • Requires careful detailing of: – – – – the duration of mood episodes qualitative emotional shifts recurrent triggering events longitudinal patterns (episodic vs lasting) Exception: BPD & rapid cycling forms of bipolar disorder mood characteristics are less reliable in differential diagnosis Both disorders involve a high degree of affective instability Likely to have significant biological and possibly genetic overlap Impulsivity: behaviour that occurs without reflection BPD Non-planning impulsiveness (lack of sense of the future) Impulsive acts (including suicidal behaviour) are often a function of the inability to tolerate distress Presence of hostility Impulsivity is more pervasive Bipolar In the depressed phase: non- planning impulsivity (lack of sense of the future) In the manic phase: motor impulsivity (tendency to act on the spur of the moment) Bipolar II disorder: shows attentional impulsivity (distractibility and inability to focus on a task) suicidal behaviour is predominantly found in the depressive phase is usually related to hopelessness Impulsivity is believed to be more episodic Impulsivity: behaviour that occurs without reflection (cont) BPD has more symptomatic overlap with the depressive pole of bipolar disorder than with the manic pole The highest rate of impulsivity is found in populations with co-morbid BPD and bipolar II disorder Co-morbit BPD & Bipolar may be at the highest risk for self-damaging behaviours Therefore important to make both diagnoses when appropriate Longitudinal course General perception: mood disorders are episodic and treatable, whereas personality disorders are considered life-long and treatment resistant. Reality: •bipolar disorder is usually a chronic condition • Whereas only a subset of remission-resistant BPD patients continue to show poor judgment and high treatment utilization •People with BPD often stop meeting threshold criteria eventually • Dramatic, impulsive and demanding behaviours tend to subside • Affective and interpersonal difficulties can persist Treatment implications Differentiating BPD from bipolar disorder has ramifications for treatment planning, both pharmacological and psychosocial Pharmacological treatment Mood stabilisers In bipolar I disorder patients, mood stabilizers are the first line of treatment targeting affective instability. In BPD, some mood stabilisers are used to target impulsivity and anger rather than affective instability. Antidepressants: Effective in the depressed phase of bipolar disorder and BPD. SSRIs in BPD appear to target anger and impulsivity, rather than mood symptoms There is a propensity to produce manic symptoms in bipolar (not in BPD) Atypical antipsychotics: appear to target anger and impulsivity in both BPD and bipolar. Pharmacological treatment: BPD Randomized clinical trials: mood stabilizers Antidepressants typical and atypical antipsychotics, Small sample sizes and poor effect sizes Cochrane review (2006): “insufficient data” to support any recommendations for pharmacological treatment in BPD polypharmacy can result in significant iatrogenic morbidity that may outweigh the marginal clinical benefits Pharmacological treatment : Bipolar Pharmacological treatment in bipolar disorder is far more effective than in BPD Eleven drugs are FDA-approved for the treatment of bipolar disorder 9 for mania/mixed phases 2 for depressive phases 5 for maintenance therapy Several are approved for more than one phase of the illness Psychosocial interventions - BPD Psychotherapeutic treatments have strong efficacy Treatments that focus on teaching emotion-regulation skills Dialectical behaviour therapy (DBT) Systems training for emotional predictability and problem solving (STEPPS) Schema-focused therapy Mentalization-based treatment Transference-focused psychotherapy Psycho-education is an integral component in the treatment of BPD (including family members) Psychosocial interventions : Bipolar The value of psychosocial interventions is gaining recognition as an important adjuvant treatment The therapeutic aims of psychosocial approaches for bipolar disorder include: Psycho-education stress management regularity in daily activities and biosocial rhythms John • John is a 53-year-old, never-married man with a 25 year history of gambling on the pokies and TAB. He has a 20 year history of heavy alcohol use. John describes current anxiety, irritability and depression. While he identified gambling and drinking as a problem, in session he is often preoccupied with his partner’s fidelity and whereabouts. He had rapid mood shifts in session, particularly when the discussion centered on his current romantic relationship. • John first presented to Gamblers Help services three years ago when he went to see his GP for low mood and admitted to a history of gambling. His attendance at GH has been inconsistent and his response to treatment poor. John has disengaged from the service on a number of occasions, often returning after or during periods of crisis during which he describes engaging in a number of impulsive behaviours, including gambling, sexual promiscuity and drinking. These behaviours were often triggered by interpersonal conflict. • John denied any current or past suicidal or homicidal ideation but endorsed a history of “mood swings.” John described brief ‘high’ periods of elation though his elevated mood would often be centered on feelings of hostility and anger. Thank you! Questions? • • • [email protected] [email protected] Ph: 90764700