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Dual Diagnosis: My Experience, Strength, and Hope Chris Stewart, MD “ Sometimes crazy doesn’t go away when you’re sober.” Anonymous ” Burns Brady Grand Rounds, University of Louisville Department of Psychiatry 1997 “He discussed how an addict was incorrectly diagnosed with Narcissistic Antisocial Sociopathic borderline with psychotic tendencies” “Demonstrated that impaired physician addicts could be successfully treated with a high success rate utilizing 12 step recovery and the biopsychosocial model when applied with sincerity and compassion.” “Drunker than Cooter Brown” “Drunker than Cooter Brown” Archetype for southern alcoholism Where would it fit into the DSM-V? How does humor function in this legend? Robert Frierson, MD Professor of Psychiatry, UofL SOM Director of C/L Psychiatry Program Director of Psychosomatic Fellowship Causes of Delirium to consider: Medications Benzodiazepines Infection/Metabolic UTI’s Withdrawal Alcohol Hypoxia COPD/CHF Malnutrition Thiamine deficiency Usually more than one reason. What is your Bias? Know your history….. Delirium and Psychosis This experience can be traumatic Having a mental illness is traumatic Having addiction can be traumatic Trauma is defined by the subjective experience of the individual, and therefore has no defined characteristics Ask your patients about their experience of their symptoms when they have withdrawal delirium, psychosis, mania, or other mental status changes ?Self Medication Hypothesis? Khantzian (1982) observed that Heroin addicts were using the drug to ‘soothe’ their aggression and rage. Addicts were not simply seeking pleasure Eventually he expanded his theory to how it applied to most drugs of abuse that reduce anxiety Drug addicts were predisposed to use certain drugs to help with affect regulation (ADHD/Cocaine, Social Anxiety/Alcohol) …The rest of the story This theory has been used by many to bypass understanding addiction as a primary disease. Khantzian’s worked from a psychodynamic model based on ideas from Kohut (1977) around self object needs and the vulnerable self. Theory also has been used to ignore the effects of PAWS, and substance induced ‘mental illness’ Biological/Managed Care Revolution Inpatient Psychiatry model meets managed care Shorter duration of stays beginning in the early 90’s At the same time a similar change in long term residential treatment for addiction or outright collapse Emergency Psychiatry Services at ULH Turf war over “dual diagnosis” patients between ULH and JADAC ER didn’t want to manage alcohol intoxication “They don’t belong here” The Healing Place “Is Bipolar disorder over diagnosed among substance abuse disorders?” Bipolar Disorders 2006. Stewart and El-mallakh. Interviewed subjects utilizing Structured Clinical Interview Findings were replicated 45 citations Examples of Dual Disorders: MENTAL DISORDERS Schizophrenia ADDICTION DISORDERS Bi-polar Alcohol Abuse/Depen. Major Depression Cocaine/ Amphet Borderline Personality Post Traumatic Stress Social Phobia ADHD Opiates Marijuana Polysubstance combinations Prescription drugs Post Traumatic Stress Disorder and Addiction: DUAL DIAGNOSIS TREATMENT PROJECT AT THE UNIVERSITY OF LOUISVILLE Integrating Cognitive Neuroscience Research and Cognitive Behavioral Treatment with Neurofeedback Therapy in Drug Addiction Comorbid with Posttraumatic Stress Disorder: A Conceptual Review Tato M. Sokhadze, PhD Christopher M. Stewart, MD Michael Hollifield, MD Journal of Neurotherapy 2007 Dual Diagnosis Project cont’ Sokhadze, E., Stewart, C., Sokhadze, G., Hollifield, M., & Tasman, A. (2009) Neurofeedback and motivational interviewing based biobehavioral treatment in cocaine addiction. Journal of. Neurotherapy, 13, 84-86 Sokhadze, E., Stewart, C., Sokhadze, G., Husk, M, & Tasman, A. (2009) Effects of neurofeedback-based behavioral therapy on ERP measures of executive functions in drug abuse. Journal of Neurotherapy, 13(4), 260-262. Sokhadze, E., , Stewart, C., El-Baz, A., Ramaswamy, R., Hollifield, M., & Tasman, A. (2009) Induced EEG gamma oscillations in response to drug- and stress-related cues in cocaine addicts and patients with dual diagnosis. Journal of Neurotherapy, 13(4), 270-271. Sokhadze, E., Stewart, C., Hollifield, M., and Tasman, A. “Event related potential study of executive dysfunctions in a speeded reaction task in cocaine addiction. Journal of Neurotherapy, 2008, v.12, N.4. Sokhadze, E., Stewart, C., Hollifield, M., and Tasman, A. “Attentional bias to drug related and stress related pictorial cues in cocaine addiction co morbid with post-traumatic stress disorder.” Journal of Neurotherapy, 2008, v 12, N.4. Surgeon General’s Report 2016 on Alcohol and Substances 20 million persons with addiction in the United States Most patients have never been asked/screened about their drug/alcohol use. Co-occurring disorders are mentioned only briefly. Emphasis on the brain diseases aspect of addiction and brain exposure to chronic drug use, “not a moral issue” Represents a major milestone in the history of addiction and addiction treatment. Strong scientific evidence for effectiveness of 12 step recovery and the need for long term strategy. Believe it or not, In my practice, on average, every two weeks I interview a patient who is asking to see me about their use of alcohol Recently a patient stated he had never had anyone suggest to him that he stop Or – no one has asked them about whether their drinking was a problem despite the fact that they were complaining of depression/anxiety Also, often I hear, “no one ever asked me….: trauma, addiction, past family history of addiction” What’s my diagnosis Doc? How long have you been sober? IF not sober, has there been a considerable period of time when you were? If not, then it will be difficult to answer this question outside of the substance use, if not impossible Did either of your parents have a problem with alcohol? DSM-V Differential Diagnosis Handbook “The process of DSM-5 differential diagnosis can be broken down into six basic steps: 1) ruling out Malingering and Factitious Disorder, 2) ruling out a substance etiology, 3) ruling out an etiological medical condition, 4) determining the specific primary disorder(s), 5) differentiating Adjustment Disorder from the residual Other Specified and Unspecified conditions, and 6) establishing the boundary with no mental disorder. “ DSM-V handbook of differential diagnosis. Likelihood of a Suicide Attempt Risk Factor Increased Odds Of Attempting Suicide Cocaine use 62 times more likely Major Depression 41 times more likely Alcohol use 8 times more likely Separation or Divorce 11 times more likely NIMH/NIDA ECA EVALUATION The Four Quadrant Framework for Co-Occurring Disorders A four-quadrant conceptual framework to guide systems integration and resource allocation in treating individuals with cooccurring disorders (NASMHPD,NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002) High severity Less severe mental disorder/ more severe substance abuse disorder Less severe mental disorder/ less severe substance abuse disorder Low severity More severe mental disorder/ more severe substance abuse disorder More severe mental disorder/ less severe substance abuse disorder High severity Not intended to be used to classify individuals (SAMHSA, 2002), but . . . DSM-V Controversy Case Example 1 “Can you prescribe my medication? 32 year old single woman with a history of ADHD since college, who is prescribed amphetamines. The reason for the office visit is for the purpose of needing a psychiatrist to manage her medications She has a degree in business and works in marketing, recently in a new position. She was treated for an eating disorder when 14 in an intensive outpatient treatment program, and has been abstinent from her behavior since college. The seduction of a psychiatric diagnosis….. ADHD and Bipolar disorder These diagnoses and others share a common theme: Often missed and/or misdiagnosed/overdiagnosed Not obvious, under the surface (like a bear in the woods) Great imitators (like addiction!) The “eureka” feeling and/or satisfies managed care paradigm – “Now we have an explanation” Case example Family history is significant for a father who “was an alcoholic” and quit drinking on his own ten years ago after consecutive DUI’s. She views her childhood as “normal” She has a new boyfriend, who is a former professional wrestler, and who is a daily marijuana smoker. I agreed to prescribe her medication after reviewing her electronic pharmacy record, which shows refill pattern consistent with her history “Oh, by the way….She also takes occasional Ativan at bedtime She doesn’t drink alcohol. Shame Patient tried to stop her medications on her own due to feeling “gross” about taking them Binges/Purges when doesn’t take her medications Identified that she uses relationships like a drug, and keeps a stash Her parents really aren’t sober (Neither is she) Neither is she ACE pyramid ACE Study continued The ACE score, a total sum of the different categories of ACEs reported by participants, is used to assess cumulative childhood stress. Study findings repeatedly reveal a graded dose-response relationship between ACEs and negative health and well-being outcomes across the life course. Dose-response describes the change in an outcome (e.g., alcoholism) associated with differing levels of exposure (or doses) to a stressor (e.g. ACEs). A graded dose-response means that as the dose of the stressor increases the intensity of the outcome also increases. Adverse Childhood Events: As the number of ACEs increases so does the risk for the following*: Alcoholism and alcohol abuse Multiple sexual partners Chronic obstructive pulmonary disease Sexually transmitted diseases Depression Smoking Fetal death Suicide attempts Health-related quality of life Unintended pregnancies Illicit drug use Early initiation of smoking Ischemic heart disease Early initiation of sexual activity Liver disease Adolescent pregnancy Poor work performance Risk for sexual violence Financial stress Risk for intimate partner violence Poor academic achievement Alcoholics Anonymous What does Attachment Theory say about Addiction? An attempt at self repair that fails (Kohut 1977) Addiction further prevents healthy repair from occurring thru isolation and increased emotional dysregulation Until an addict learns to develop the capacity for mutually satisfying relationships they are vulnerable to relapse. It's hard to be humble when you're as great as I am. Muhammad Ali Healthy Narcissism Giving and receiving are balanced Recognition of the other in a positive way Necessary for healthy self esteem NOT a insecure defense against humiliation and shame NOT inflated sense of self Healthy dependency on others is accepted NOT Codependency or Counterdependency The brain opioid theory of social attachment Children with poor attachments exhibit lower opiate receptor density (Flores 2005) Kraemer’s (1985) peer monkeys and isolation syndrome Dysregulation of opioid, Serotonin, Dopamine, NE FMRI’s of the Brain of patients experiencing pain compared with patients experiencing rejection/loss (Eisenberger and Lieberman, 2003) Depression and isolation increase Mu activity Secure versus Insecure Attachment Secure attachment liberates. (Safety permits play) Insecure leads to patterns of either rigidity or chaos (Siegel) Secure attachment maintains homeostasis Insecure attachment destabilizes Secure attachment is required throughout the lifespan Isolation causes increased stress and poorer health outcomes across the lifespan Thanks Sarah Acland Burns Brady Jay Davidson Robert Frierson Greg Jones Arthur Meyer Estate Sokhadze
