Download Training - Illinois Co-Occurring Center for Excellence

Psychiatric Aspects of Adolescent
Co-occurring Disorders
Seth Eisenberg MD
Medical Director, DHS-DASA
October 24, 2011
1
Eisenberg Outline
Similarities and relationships between AOD
and psych symptoms
 Mental Status Exam, Diagnosis and
Psychiatric Symptoms
 Anxiety Disorders
 Elements of Medication Treatment
 Adolescent Gambling
 Ask the Doc

2
AOD Use and Psychiatric Symptoms
AOD use can cause psychiatric symptoms and mimic psychiatric
syndromes.
AOD use can initiate or exacerbate a psychiatric disorder.
AOD use can mask psychiatric symptoms and syndromes.
AOD withdrawal can cause psychiatric symptoms and mimic
psychiatric syndromes.
Psychiatric and substance use disorders can independently
coexist.
Psychiatric behaviors can mimic substance use problems.
SAMHSA TIP #9
3
Drugs That Precipitate or Mimic Mood Disorders
Mood Disorders
Depression
and dysthymia
Mania and
cylothymia
During Use
(Intoxication)
Alcohol,
benzodiazepines,
opioids, barbiturates,
cannabis, steroids
(chronic), stimulants
(chronic)
Stimulants, alcohol,
hallucinogens,
inhalants (organic
solvents), steroids
(chronic, acute)
After Use
(Withdrawal)
Alcohol,
benzodiazepines,
barbiturates, opiates,
steroids (chronic),
stimulants (chronic)
Alcohol,
benzodiazepines,
barbiturates, opiates,
steroids (chronic),
SAMHSA TIP #9
4
Adolescent Dependency
GENERAL EFFECTS
The adolescent demonstrating these behaviors may
be indicating a problem with drugs and/or alcohol:




Sudden, noticeable personality changes
Severe mood swings
Changing peer groups
Dropping out of extra-curricular activities
ADOL-CD Cont’d
5
GENERAL EFFECTS
Decreased interest in leisure time activities
 Worsening grades
 Irresponsible attitude toward household
jobs and curfews
 Depressed feelings much of the time
 Dramatic change in personal hygiene
concern
 Changes in sleeping or eating habits

ADOL-CD Cont’d
6
GENERAL EFFECTS
Smell of alcohol or pot
 Sudden weight loss
 Tendency toward increasing dishonesty
 Trouble with the law
 Truancy from school

ADOL-CD Cont’d
7
GENERAL EFFECTS
Frequent job losses or changes
 Turned off attitude if drugs are discussed
 Missing household money or objects
 Increasing time alone in his/her room

ADOL-CD Cont’d
8
GENERAL EFFECTS
Deteriorating family relationships
 Drug use paraphernalia, booze, or empty
bottles found hidden
 Observations of negative behavior by
people within or outside immediate family
 Obvious signs of physical intoxication

ADOL-CD Cont’d
9
GENERAL EFFECTS
Some of these behaviors are a sign of typical
adolescent development, BUT,
a wide variety of them in one person should raise
suspicions of the likelihood of harmful involvement
with drugs or alcohol….
OR—some kind of psychiatric problem
ADOL-CD Cont’d
10
Adolescent Comorbidity
The syndrome most consistently associated
with substance use is
delinquent behavior,
followed by scales measuring
social problems and attention problems
11
Adolescent Comorbidity
The likelihood of substance use among
adolescents is associated with the severity of
emotional and behavioral problems across age
and gender groups.
12
Adolescent Comorbidity
Past-month marijuana use was nearly 2x as
likely and use of other drugs was 4x more likely
for adolescents with serious emotional
problems than for adolescents with low levels
of emotional problems.
13
Adolescent Comorbidity
Past-month marijuana use was 4x as likely,
and use of other drugs was nearly 7x more
likely, for adolescents with serious
behavioral problems than for adolescents
with low levels of behavioral problems.
14
Adolescent Comorbidity
Dependence on substances such as cocaine,
crack, inhalants, hallucinogens, heroin or
prescription drugs was nearly 9x as likely
among adolescents with serious behavioral
problems.
15
Adolescent Comorbidity
Past-month alcohol use was nearly 2x as likely for
adolescents with serious emotional problems
than for adolescents with low levels of emotional
problems.
16
Adolescent Comorbidity
Adolescents with serious behavioral problems were
nearly 3x as likely to use alcohol in the past month
than adolescents with low levels of behavioral
problems
17
Adolescent Comorbidity
Adolescents with serious emotional problems
were nearly 4x more likely to be dependent on
alcohol or illicit drugs than adolescents with low
levels of emotional problems.
18
Adolescent Comorbidity
Alcohol or drug dependence was more
likely among adolescents with serious
behavioral problems than among
adolescents with low levels of behavioral
problems
19
Adolescent Comorbidity
Stealing, swearing, hanging around with
troublemakers and running away from home Feeling confused or in a fog
were associated with more substance use
20
Adolescent Comorbidity
While overall substance use is generally higher for
adolescent males than for females, females with
high ratings for psychosocial problems as
measured by the YSR were as likely as males to
smoke cigarettes, binge drink or use illicit drugs.
21
Adolescent Comorbidity
Risk Factors
• Juvenile Delinquency
• Runaways
• High School Dropouts
• Youth With Psychiatric Disorders
• Unmarried Pregnant Adolescents
• Youth That Have Been Physically,
Sexually, or Emotionally Abused
22
Adolescent Comorbidity
Risk Factors
• Unsatisfactory Family Relations
• Children in Foster Care
• Extreme Sexual Activity
• Exploited Youth
• School Difficulty - Low G.P.A.
23
Adolescent Comorbidity
Risk Factors
• Family Social Deprivation, i.e., Poverty
• Association with Delinquent Peers
• Neighborhood/Community
Disorganization
• Affiliation with Peers of Other
Dysfunctional Family Systems
24
Adolescent Comorbidity
Characteristic Profile
• More Impulsive
• Less Mature
• More Peer Oriented
• Restless (tension reduction oriented)
25
Adolescent Comorbidity
Characteristic Profile
• Rebellious
• Increased Sadness
• Increased Social Withdrawal
• Learning Problems
26
Adolescent Chemical Dependency
Individual Risk
Low self esteem
 Feelings of not belonging
 Poor coping skills
 Poor interpersonal skills
 Poor situational skills, poor judgement
 Biogenetic factors

ADOL-CD Cont’d
27
Adolescent Comorbidity
When Compared to Non-CD Psychiatric Cases
• Earlier First Use of Drugs (14 vs 12)
• Increased Divorce (56% vs 26%)
• Increased Parental CD
• Increased Parental Psychiatric Illness
28
Adolescent Comorbidity
When Compared to Non-CD Psychiatric Cases
• More Legal Problems
• Increased Special Education Placement
• More Frequent Suicide Attempts
• Increased Residential Placement
29
Adolescent Comorbidity
Associated with:
• Earlier Onset of Abuse Behaviors
• Greater Clinical Severity
• Poorer Outcomes
• Increased Disturbance of Relationships
30
Adolescent Comorbidity
Associated with:
• Differential Responsiveness to CD
Treatment
• Increased Risk of Relapse
• Less than Optimal Functioning when
Abstinent
31
Adolescent Comorbidity
Diagnostic Considerations
• Impact of Chemical Use
-decreased withdrawal symptoms
-varied expression of use
-negative effect on development
• Emerging Psychiatric Illness
-usual age of onset
-precipitating event
32
Adolescent Comorbidity
Diagnostic Considerations
• Commonality of Symptoms of Psychiatric Disorders
- ADHD, bipolar, depression, CD, anxiety
• Confounding Symptoms of Adolescent CD
- Intoxication
- Chronic use
- ABCD-S
33
Adolescent Comorbidity
Adolescent Behavior CD Syndrome
• High Delinquency
• Hyperactivity
• Decreased School Performance
• Decreased Social Competence/Participation
• Depressed Behaviors
• Onset after development of CD and
subsides 2 months after onset of sobriety
34
Adolescent Comorbidity
ABCD-S (Continued)
• May Result In:
-developmental dysfunction
-hyperactivity, distractibility
-restlessness, impulsivity
-depression and suicide
• Possible Overdiagnosis of Psychiatric
illness
35
Diagnostic Dilemmas

Psychoactive substances have profound
effects on neurotransmitter systems
– Neurotransmitters may be involved in
psychiatric disease states
– May unmask genetic vulnerability
– May cause a psychiatric disease

It may be difficult to differentiate which
diagnosis is primary, ie which “came first”
36
Psychiatric Diagnosis
Mental Status Exam and Psychiatric
Symptoms
37
MENTAL STATUS EXAMINATION
(MSE)
Formal or MINI MSE
APPEARANCE
SPEECH
EMOTIONS (mood & affect)
THOUGHT PROCESS
THOUGHT CONTENT
PERCEPTIONS
ORIENTATION
MEMORY
CONCENTRATION
INSIGHT
JUDGMENT
IMPULSE CONTROL
38
MENTAL STATUS EXAMINATION (MSE)
Appearance
– Physical appearance, mannerisms, attitude
Speech
– Rate, rhythm, volume, articulation
Mood
– “how do you feel today”
Affect
– Outward expression of inner mood: range,
intensity, stability, appropriate
39
MENTAL STATUS EXAMINATION (MSE)
Thought Process
– Productivity, continuity, coherence
Thought Content
– fears, obsessions, paranoia, suicide, violence
Perceptions
– Hallucinations and illusions, depersonalization
Orientation and Cognition (formal MSE)
40
Overview of Psychiatric Disorders
and Symptoms
Schizophrenia and Psychosis
 Mood Disorders
 Anxiety Disorders
 ADHD and Impulse Control Disorders
 Personality Disorders
 Developmental Disorders
 Sleep Problems

41
Schizophrenia and
Other Psychotic Disorders
Schizophrenia
 Schizophreniform
 Schizoaffective Disorder
 Delusional Disorder
 Brief Psychotic Disorder
 Substance Induced Psychotic Disorder

42
Symptoms of Psychosis
Hallucinations
 Delusions (bizarre and non-bizarre)
 Disorganized speech
 Disorganized thinking
 Disorganized behavior or catatonia
 “negative symptoms”

43
Antipsychotics/Neuroleptics
Traditional—First Generation


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
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

chlorpromazine
fluphenazine
haloperidol
perphenaxzine
thioridazine
thiothixene
trifluoperazine
Thorazine, Prolixin,
Haldol (decanoate),
Trilafon, Mellaril,
Navane, Stelazine
44
Antipsychotics/Neuroleptics
Atypical, Novel—Second Generation






aripiprazole
clozapine
olanzapine
quetiapine
risperidone
ziprasidone
Abilify, Clozaril, Zyprexa
(zydis), Seroquel,
Risperdal Geodon,
Saphris, Fanapt,
Latuda
• Consta
• Invega Sustena
• Relprev
45
Mood Disorders

Depressive Disorders
– Major Depressive Disorder
– Dysthymic Disorder

BiPolar Disorders
– Bipolar I
– Bipolar II
Cyclothymic Disorder
 Substance Induced Mood Disorder

46
Symptoms of Depression
Depressed mood, sadness, crying
 Decreased interest and pleasure
 Decreased energy and activity
 Weight change, sleep change
 Low self esteem, worthlessness, guilt
 Decreased concentration
 Suicidal ideation

47
ADOLESCENT COMORBIDITY
Depression
•Mostly studied - high prevalence in adults
•Approximately 80% clear in two weeks
•In adolescents - frequent suicidality
•Suicide attempts with increased medical
seriousness and lethality
•Family history important
•Developmental history important
48
Antidepressants
SSRIs






citalopram
escitalopram
fluoxetine
fluvoxamine
paroxetine
setraline
Celexa, Lexapro, Prozac,
Prozac weekly,
Sarafem
Luvox, Paxil, Paxil CR,
Zoloft
Cymbalta, Pristiq, Paxeva
49
Antidepressants
Tricyclics


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


amitriptyline
clomipramine
desipramine
doxipin
imipramine
maprotiline
nortriptyline
protriptyline
Elavil, Anafranil,
Norpramin, Sinequan,
Tofranil, Ludiomil,
Pamelor, Vivactil
50
Antidepressants
Others







buproprion
mirtazapine
trazadone
venlafaxline
isocarboxazide
phenelzine
tranylcypromine
Wellbutrin (SR, XL),
Remeron, Deseryl,
Effexor (ER), Marplan,
Nardil, Parnate
51
Symptoms of Bipolar Mania
Elevated, expansive mood of well being
 More irritable or agitated
 Grandiose delusions
 Decreased need for sleep
 More talkative than usual
 Racing thoughts
 More action and activity
 Increased distractibility

52
Antimanic Medications
lithium
 carbamazepine
 divalproex sodium
 gabapentin
 lamotrigine
 oxcarbazepine
 Topiramate
Atypical Antipsychotics

Eskalith, Tegratol,
Depakote, Neurontin,
Lamictal, Trileptal,
Topamax
53
Anxiety Disorders
What is Anxiety?
54
Symptoms of Anxiety
-
autonomic hyperactivity
-
increased hand tremor
insomnia
nausea or vomiting
psychomotor agitation
Anxiety
Nervous, tense, fearful and high strung
55
Symptoms of Anxiety
Panic attacks and fear of panic attacks
 Excessive worry about everything
 Intrusive memories, flashbacks, fears
 Excessive anxiety in social situations—fear of
negative judgment and embarrassment
 Repeating thoughts or behaviors

56
Anxiety Disorders
Panic Disorder--with agoraphobia
 Social Phobia
 Generalized Anxiety Disorder
 Obsessive-Compulsive Disorder
 Acute Stress Disorder
 Posttraumatic Stress Disorder
 Substance-Induced Anxiety Disorder

57
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

58
Agoraphobia
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

59
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
60
Social Phobia
“Marked and persistent fear of social or performance
situations in which embarrassment may occur” (DSM
IV)
 Prevalence 12% to 56% in alcoholic
populations
 May interfere with treatment
 Specific symptoms for diagnosis
 SSRIs (delayed effect)
61
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
62
Obsessive-Compulsive Disorder
Obsessions
 Recurrent persistent thoughts, impulses or
images—intrusive and inappropriate and cause
anxiety or distress
 Not simply excessive worries
 Person attempts to ignore or suppress or
neutralize
 Recognized as a product of own mind
63
Obsessive-Compulsive Disorder
Compulsions
 Repetitive behaviors or mental acts the person feels
driven to perform in response to obsession or
according to certain rules
 The behaviors or mental acts are aimed a preventing or
reducing distress or preventing some dreaded act (not
realistic)
 At some point are recognized as excessilve or
unreasonable
 Cause marked distress or are time consuming or
significantly interfere
64
Acute Stress Disorder
Exposed to traumatic event with serious threat
and feelings of intense fear, helplessness or
horror
 During or after event had three or more:

–
–
–
–
–
Numbing, detachment or lack of emotions
Reduction in awareness of surroundings
Derealization
Depersonalization
Dissociative amnesia
65
Acute Stress Disorder
Traumatic event is re experienced with
images, thoughts, dreams, flashbacks, reliving
or distress with reminders
 Marked avoidance of stimuli that remind
 Marked symptoms of anxiety or increased
arousal (poor sleep, irritable, startle, etc)
 Causes significant distress or impairment
 Lasts a minimum of 2 days and maximum of 4
weeks and occurs w/in 4 weeks

66
Post-Traumatic Stress Disorder
“Development of symptoms following exposure to
an extreme traumatic stressor” (DSM IV)
 30% to 50% prevalence in SUD treatment
seekers
 Goal to reduce key symptoms
 Target symptom constellations
 TCAs and MAOI’s - Depressive and
intrusive
 Neuroleptics - Psychosis and dissociation
 Carbamazipine - Impulse dyscontrol
 Clonidine, Beta Blockers, Benzos arousal
 SSRIs
67
ADOLESCENT COMORBIDITY
PTSD
•Child/adolescent sexual and physical
abuse
•Increased depression, anxiety, negative
self concept, suicidal behavior
•Adolescent antisocial behavior
68
ADOLESCENT COMORBIDITY
PTSD
•Increased school problems, run away,
placement, legal difficulties
•More drugs with more frequent use
•Motivation for substance use
-reduce tension
-sleep
-relieve pain or discomfort
-escape family problems
69
Antianxiety Medications

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alprazolam
chlordiazepoxide
clonazepam
diazepam
lorazepam
oxazepam
buspirone
propranolol
hydroxyzine
Xanex, Librium,
Klonopin, Valium,
Ativan, Serax, Buspar,
Inderal, Atarax
(Vistaril)
SSRIs
Atypicals
70
Anxiety Disorders and SUD
Medication 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 relapse—use low dose
initiation
 Latency of onset of effect, 2-6 weeks
 SSRIs—no abuse potential, safe, generally well
tolerated, may help with ETOH
71
Anxiety Disorders and SUD
Medication 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 excitability
TCAs carry risk of lower seizure threshold and
interactions with ETOH, depressants and stimulants
72
Anxiety Disorders and SUD
Medication 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
73
Anxiety Disorders and SUD
Medication Treatment
Generalized Anxiety Disorder (8-52% in AUD, 21%
in MMT, 8% in cocaine)
 Diagnostic difficulties—overlap with symptoms
of acute intoxication with stimulants and
withdrawal from alcohol and sedatives (and
anxiety in early recovery--PAWS)
 SSRI, TCA, venlafaxine, anticonvulsants
 Use of benzodiazepines is controversial
 Buspirone may be effective
74
Comorbid Anxiety and Alcohol
Which Comes First?
Risk of getting new ETOH Dep as a Jr/Sr more
than tripled among students with anxiety dx as a
freshman.
 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

75
Comorbid Anxiety and Alcohol
Comorbidity Models
1.
Having an anxiety disorder predisposes one to
develop an SUD via self medication
–
2.
The social, occupational and physiologic
effects of substance use can generate new
anxiety symptoms in vulnerables
–
3.
“anxiety induced” substance use disorder
Not the same as “substance induced”
Third factor can serve as a common cause for
both conditions (underlying genetic or physiologic
liability)
76
ADHD

Hyperactivity and inattention
– Impulsive, overactive, impatient, intrusive
– Distracted, poor concentration, procrastinates,
disorganized and forgetful
77
ADOLESCENT COMORBIDITY
Attention Deficit/Hyperactivity Disorder
•Differential Diagnosis -bipolar
-LD
-Mood and anxiety
-ABCD-S
•Psychiatric Cormorbidity
•Multiple Risks for Substance Abuse
•In Adults
78
ADOLESCENT COMORBIDITY
AD/HD - Treatment Considerations
•Require Special Programming
•Chronic Experience of Failure
•Mood Problems - Self Esteem
•Disruptive Behaviors
•Learning Problems
•Difficult family Situations
79
Stimulant Medications
and Non-Stimulants


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D-amphetamine
L & d-amphetamine
Methamphetamine
Methylphenidate
Pemoline
Modafinil
Atomoxetine
Bupropropion
Guanefacine-clonidine
Dexedrine,
Adderall, Desoxyn,
Ritalin, Concerta,
Metadate, Focalin,
Cylert, Provigil,
Strattera,
Wellbutrin, Tenex
Intuniv
80
Personality Disorders
Antisocial Personality Disorder
 Paranoid Personality Disorder
 Schizoid and Schizotypal PD
 Borderline Personality Disorder
 Narcissistic Personality Disorder
 Avoidant Personality Disorder
 Dependent Personality Disorder

81
Developmental and Organic
Disorders
Mental Retardation and other syndromes
 Autism and Asperger’s
 Learning Disabilities
 Communication Disorders
 Tic Disorders
Cognitive impairment from seizures, traumatic
brain injury, medical, drugs and alcohol

82
Medication Treatment of Psychiatric
and Substance Use Disorders
Psychotherapeutic Medications: What
Every Counselor Should Know
Mid-America Addictions Technology Transfer Center
83
Medication Treatment
General Principles
Pharmacologic effects:
 Therapeutic—indicated purpose and
desired outcome
 Detrimental—unwanted side effects (may
interfere with adherence), potential for
abuse and addiction
Need a balance between therapeutic and
detrimental
84
Medication Treatment
General 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
85
Medication Treatment
General Principles
Many medications are non-psychoactive
(except for mild side effects including sedation
or stimulation)
 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)

86
Medication Treatment
General Principles
Positive reinforcement—increase 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 patients
87
Medication Treatment
Stepwise 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

88
Medication Treatment
Stepwise Treatment Model
High risk patients with anxiety disorder
1. Non-pharmacologic approaches when
possible
2. Non-psychoactive medications added next as
adjunctive treatment
3. Psychoactive medications when other
treatments fail
89
Medication Treatment
Stepwise 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 undermedicating
 Different treatments should be complementary,
not competitive

90
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.

91
Medication Adherence
Comorbid SUD: a Risk for Non-adherence
May have conflicted feelings and attitudes
about medication
 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

92
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
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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 don’t like pills (or meds)”.
– Elicit a reason—never needed it, cured now, don’t
believe in it, means I’m crazy, side effects, afraid, shame,
cost, interpersonal, want to be in control, do it on my
own, can’t use
– Motivational Interviewing
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Using an Empathic Style
An Empathic Style
 Communicates respect for and acceptance of
clients and their feelings
 Encourages a nonjudgmental, collaborative
relationship
 Allows the clinician to be a supportive and
knowledgeable consultant
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Using an Empathic Style
An Empathic Style
 Compliments and reinforces the client
whenever possible
 Listens rather than tells
 Gently persuades, with the understanding that
the decision to change is the client’s
 Provides support throughout the recovery
process
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Motives for Adolescent
Gambling Behavior
Relaxation
Enjoyment, Excitement, Entertainment
Adventure, Attention
Opportunity
Negative feelings
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Why Do Youth Gamble?
Excitement
 Entertainment
 Escape
 Economics
 Ego

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Psychiatric Comorbidity
Effects of Family Gambling




May be effected directly or indirectly
Impact on kids depends on how disorganized or
dysfunctional the family is to begin with and how
much gambling disrupts family routines
Impact is greater if parents are pulled away from
their roles as caretakers
Impact on children also related to:
– .Age of children
– .Underlying personalities and character
– .Amount of marital discord
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Psychiatric Comorbidity
Effects of Family Gambling




Children may feel responsible for things they
don’t understand and become anxious and guilt
ridden—they may develop certain roles they
play in the family
Children may get pulled into deceit and
subterfuge by the gambler parent
Experience may ultimately shape the child’s
values about money
Children may manifest a wide variety of
behaviors and moods at home, at school or in
the community
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Psychiatric Comorbidity
Most consistent finding is depression
 Themes of guilt, self-punishment
 Hopelessness, lack of motivation, suicide
and loneliness
 Self-destructive excessive risk-taking
 Significant life events before depression
 2/3 of life events after gambling
 Subsets of gamblers

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Psychiatric Comorbidity
DSM-IV
Depression-with high suicidality
 Bipolar Disorder and Cyclothymia
 ADHD
 Personality Disorders (APD, NPD, BPD)
 General medical conditions with stress
 Substance use disorders
 Urge to gamble increases during periods of
stress or depression

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Psychiatric Comorbidity
Psychiatric Typology-Blaszczynski
“Normal” problem gamblers
 Emotionally disturbed gamblers
 Biological correlates of gambling

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Pathological Gambling and
Substance Abuse
More severe substance abuse history
 More episodes of overdose
 More prior AOD treatment
 Used a greater variety of drugs
 Greater past use of ETOH, opiates and
solvents
 Greater history of legal problems

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Why Harm Reduction
for Adolescent Gambling
Gambling is a SOCIALLY ACCEPTABLE
ACTIVITY
 Entertainment
 Unique: no social barriers
 Promoted in the home environment

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Adolescent Chemical Dependency
Treatment and Outcomes
•Multidimensional and multidisciplinary
•Developmental status - habilitation vs.
rehabilitation
•Flexibility - stages of change
•Family therapy - family issues
•Treatment programs - long term OP vs.
short term inpatient
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Adolescent Chemical Dependency
Treatment and Outcomes
•Treatment completion, parental involve- ment
and aftercare
•Good social supports, self esteem and coping
skills
•Greatest relapse risk during first 3 months
(>60%)
•Relapse associated with delinquency, social
and peer influence, drug craving, less
productive and recreational activities
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Ask the Doc
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