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Dual Diagnosis Dr Nikki Wood Principal Clinical Psychologist Forensic Dual Diagnosis Service John Howard Centre Definitions • The term “dual diagnosis” is generally applied to people who have two or more diagnosed disorders • Combined mental health and substance use problems • More than “dual problems”- likely to have complex health and social needs • Wide range of people with varying degrees of need (c.f. individualised treatment) Severity of problematic HIGH Substance Misuse e.g. a dependent drinker who experiences increasing anxiety e.g. an individual with schizophrenia who misuses cannabis Severity of Mental Illness LOW e.g. a recreational misuser of ‘dance drugs’ who has begun to struggle with low mood after weekend use HIGH e.g. an individual with bipolar disorder whose occasional binge drinking and experimental misuse of other substances destabilises their mental health LOW “Mainstreaming” DH (2002) Good Practice Guide: • Doesn’t advocate a separate specialist service for dual diagnosis • Mental health services should take primary responsibility for those with serious mental health problems (like schizophrenia) and substance use • Substance use services should take primary responsibility for those with primary substance problems and common mental health problems (anxiety, depression) • However mental health and substance use services should work together and support each other Consequences in dual diagnosis • • • • Young, single, male, homeless lower educational and employment attainment higher rates of relapse longer inpatient stays (twice as long - Menezes et al, 1996) • non-adherence to medication • higher rates of violence, suicide and self harm • higher likelihood of involvement with the criminal justice system, (Drake and Meuser, 2000) • Poor physical health - higher rates of HIV, Hep B and C, and other substance use related physical problems • Family problems • Difficulties getting access to appropriate aftercare • High overall service costs • Higher overall risk of untoward incidents (Drake and Meuser, 2000) Nutt, King &Phillips, (2010) Drug harms in the UK: a multicriterion analysis, Lancet, online 1st November 2010 Reasons For Drug Use (in people with mental health problems) • Hedonism, escape and fun • Self medication • Cravings • Medicate medication side-effects. • Peer acceptance/ social factors. • Boredom. • Coping with stressful relationships/situations Self-medication • The use of substances to alleviate painful or uncomfortable emotional or physical states. • Positive and negative symptoms of psychosis (apathy, flattened affect, slowed thoughts) • Side-effects of medication (EPSE, akathisia, neuroleptic dysphoria) • General distress as a result of having a chronic illness (boredom, loneliness, distressing symptoms, labelling) • Although this hypothesis is not fully supported by the research, and could be considered a convenient medical model explanation Bio-psycho-social model of Psychosis • Developing psychosis is a combination of biological, psychological and social factors • Biological factors include genes and a history of mental illness in the family • This would lead individuals to be more prone to developing psychotic symptoms at times of stress (stress-vulnerability model) • Substance use is also likely to affect the brain chemicals of vulnerable people Zubin & Spring’s Model of the Interaction Between Vulnerability & Stressful Events in Triggering an Episode of Schizophrenia (1977) Maximum ill Challenging Events Threshold Well Minimum Low High Vulnerability Psychological factors • Anxiety and depression • Stress • Poor coping and social skills • Difficult early childhood experiences • Poor self esteem and sense of self • Unusual perceptual experiences • Perception of events as personal and traumatic Social Factors • Substance use • Homelessness • Financial worries and social deprivation • Work/school problems/family conflict • Difficult relationships with others • Isolation –leads to poor reality testing • Major life events Drugs and mental health Cannabis • Known as skunk, weed, resin, ganja, grass, blow, hash, spliff, sensi, sensimilla, smoke • Was reclassified to Class B in January 2009 • Is usually smoked with tobacco rolled in a Rizla paper. • Main active ingredient is ∆THC (tetrahydrocannabinol) • Cannabis can cause anxiety, panic attacks, paranoia and restlessness Cannabis • People with psychotic symptoms are more than twice as likely to use cannabis as those without • Why is this? The jury is still out but may be selfmedicating • However research suggests that cannabis use, especially the use of stronger forms of cannabis such as skunk, can increase the likelihood of developing schizophrenia in psychosis-prone individuals • New research has found there is a particular marker gene for a negative response • Age of first use also a factor Does cannabis cause sz? • Does cannabis cause schizophrenia? – Childhood use found to double chances of schizophrenia in later life – Andreasson et al 1987 • The higher the frequency of use prior to age 18 the more likely to develop schizophrenia – Arseneault et al 2002 • If using by 15 you are 4.7% more likely to develop schizophrenia • If using by 18 you are 10.3% more likely to develop schizophrenia • Semple et al (2005) in their meta-analysis found that early use of cannabis was related to an increased risk of psychosis, and vulnerable groups were those who had used cannabis at a very early age, those who had already experienced psychotic symptoms and those with a genetic risk for developing SZ. • Vigella (2008) also found that frequency of use was also a factor with daily cannabis use found in 66% of their early onset sample • Cannabis potency recently confirmed to be a factor (Di Forti et al, 2009; n=280) with skunk increasing the risk of psychosis 6.8 times. Length of use (more than 5 years) and frequency (daily) also found to be factors. • However Hickman (2009) found that you would need to stop 2,800 heavy male users or more than 5,000 heavy female users to prevent a single case of schizophrenia Cannabis • Recent research has found that some chemicals in cannabis may have antipsychotic and antianxiolytic effects - cannabidiol (CBD) • which may explain why some people keep on using it despite the THC sometimes making other symptoms worse. e.g. paranoia • Some evidence that there can be paranoia and agitation on withdrawal – psychological dependence? • Harm minimisation most helpful, smoke less, and smoke less strong versions e.g. avoid skunk and sensimilla So cannabis use can contribute to the development of psychosis, especially the use of skunk at an early age And ongoing and frequent use can make symptoms worse or lead to a relapse But also used to help with symptoms – paradox! New research has found there is a particular gene that may in the future mark out who is more vulnerable to psychosis and who will have a negative effect from cannabis Alcohol • • • • • • Is a CNS depressant At low doses has a disinhibiting effect At higher doses leads to dysphoria/low mood Depressive effects are transient Strongly linked with violence and suicide Is also a factor in personality disorder and pathological jealousy • Use common with axis 1 and axis 2 disorders • May be used to manage hyperarousal or agitation but also masks symptoms • Also used to cope with physical pain • Withdrawal could lead to increased arousal and exacerbation of symptoms • Used as a means of avoidance –cognitive and emotional • May relieve feelings of isolation, loneliness, emptiness and anxiety • Prolonged excessive use can lead to brain and liver damage and memory problems • Also linked with heart disease and cancer. • Withdrawal/hangover can lead to anxiety • May be used to cope with anxiety, PTSD symptoms, sleep problems, social phobia and depression • Commonly used with other substances Cocaine/crack • Is a stimulant • Coke, charlie, snow, freebase • Crack is made by chemically altering cocaine powder to form ‘rocks’ • Latest figures state the street cocaine is only around 4% pure. • Cocaine is usually snorted whereas crack is smoked in a pipe • Effects are more intense when smoked as crack as gets to brain quicker – high lasts about 5 minutes • After the first pipe, the euphoric effects decrease and the withdrawal effects increase meaning people need to take more and more • General effects are: alert, energetic, confident, mentally powerful, feel physically strong, increased heart rate, dilated pupils. • On intoxication, can lead to – agitation, suspiciousness, paranoia, impaired reality testing, impaired memory • In withdrawal – depression, suspiciousness, paranoia, impaired reality testing, impaired memory • When cocaine is used with alcohol, the body creates a substance called cocaethylene, which is toxic to both heart and liver and which remains in the body for up to four or five days. • Use can lead to depression and suicidality • Formication – ‘cocaine bug’ – sensation of insects crawling under your skin • May also be used to augment hypomania, temporarily relieve depression and counteract hyperactivity and ADHD. • Risk of violence and acquisitive offending either when high or when on withdrawal and cravings in order to purchase more • Crack and cocaine may be taken in order to give permission to offend, either by numbing affect/feelings of empathy, or through increasing confidence and feelings on invincibility • Forensic patients frequently say they acted in ways when they were high on crack which they would not do if they were straight. • Crack and cocaine use associated with unsafe sexual behaviours • Addiction to crack can lead to sex working (in both males and females) and the associated risks of STD’s. Heroin • opiate based pain-killer/sedative • Class A • Known as smack, brown, scag, junk, H. Derived from the opium poppy and medical name is Diamorphine. • very addictive, both physically and psychologically especially when injected, can also be smoked. • withdrawal symptoms physically very unpleasant • Withdrawal symptoms (onset within 6 hours, and peak at 36-48 hours, lasts up to 7 days) include: Intense craving, restlessness, insomnia, pain in muscles and joints, running nose and eyes, sweating, abdominal cramps, vomiting, piloerection, dilated pupils, disturbance of temperature control • But can lead to anxiety and depression • associated with personality disorders • In London, heroin is approximately 40% pure on the street. The rest can be anything such as glucose, brick dust, lactose, baking powder, gravy browning and basically anything that resembles heroin. • Is a pain killer/emotional numbing – PTSD and abuse • May attenuate feelings of rage or violence • Can also however increase feelings of confidence and invincibility. Ecstasy/MDMA • currently not clear about long term effects – depression? Cognitive function - research is still inconclusive • may cause low mood in days following use ‘suicide Tuesday’ • is a hallucinogen so may be linked with increase in symptoms • disrupted sleep associated with use, especially in clubbing culture • In media, reports that can help those to access memories of trauma and reduce anxiety/distress levels • So use could also be self-medicating for PTSD symptoms Crystal Meth • Derivative of amphetamine • Commonly used in non-EU countries but recently use has started to increase in the UK • Can be found in tablet, powder or crystal form • Crystal form, known as crystal meths or ‘ice’ can be smoked and is most potent and harmful • Rush of 5-30 minutes depending on administration and high last for 8-24 hours • Causes increased arousal and motor activity, disinhibition, diminished fatigue, sleep and appetite. • Can lead to MA induced psychosis even after brief period of use • Long term use can also lead to brain damage • Premorbid schizoid/schizotypal PD may predispose MA users to psychosis and the greater the vulnerability, the longer the psychosis will persist • Use seems to be particularly linked to unsafe sexual behaviour and transmission of STDs • Paranoia and agitation especially linked to violence, both from use and withdrawal Other common drugs • Speed/amphetamines (stimulant) - disordered thinking, paranoia, restlessness, poor sleep, hallucinations - use can trigger psychosis in vulnerable individuals and create psychotic like symptoms when taken in large amounts - exacerbates positive symptoms • LSD/Acid – can trigger psychosis in vulnerable individuals • Miaow miaow • Khat Principles of Integrated Treatment Harm reduction • Treat/investigate medical problems e.g. BBV, access to food/vitamins, stable housing/finance, moderation goal, substitution therapy. • Time unlimited services - to allow long-term change • Motivation-based treatment – motivational interviewing • Multiple psychotherapeutic modalities - CBT based groups, 12 step programme, individual therapy, faith based rehabilitation. The Wheel of Change Drug free support group Lapse Interview NA Permanent exit Maintenance Action Stage 2 Groups and individual therapy BEGINS WITH Relapse Pre-contemplation Contemplation Preparation Ward based Stage 1 Groups