Download Working with mental health comorbidities in gambling

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
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41-60% Anxiety Disorder
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37-50% Depression: (past year)
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The Victorian Department of Justice (2009); Volberg et al (2006)
6-12% Bipolar Affective Disorder
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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).
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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:
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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
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Conditions requiring immediate attention
e.g. problem gambling; major depression; anxiety; schizophrenia, bipolar
Pervasive chronic symptoms
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Personality disorders
Developmental disorders
May not require immediate attention but may complicate treatment
Medical or neurological conditions
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Conditions that may influence a psychiatric problem.
E.g. diabetes might cause extreme fatigue which may lead to a depressive episode.
Recent psychosocial stressors
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Psychosocial and Environmental stressors
e.g. a death of a loved one, divorce, losing a job
The person’s general level of functioning
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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
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Current symptomatology (clusters of symptoms)
Stressors
Risk
Current treatment & services
Mental State Examination
• Bio-psycho-social Hx
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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
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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
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Personality Disorders x 10
Differential diagnosis
-Clinical Disorders
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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
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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:
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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?
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[email protected]
[email protected]
Ph: 90764700