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Helping the Dual Diagnosis Client Working with the complex relationships between addictions and mental health problems 6th May 2010 A person who has both a (substance) addiction problem and an emotional/psychiatric problem is said to have a dual diagnosis. The concept arises because addictions are not seen in the same way as other mental health problems – addiction is often not thought of as a mental health problem. To recover fully, the person needs treatment for both problems. Common MH Problems in DD Depressive disorders – Depression – Bipolar disorder Anxiety disorders – Generalised anxiety disorder – Panic disorder – OCD – Phobias Other psychiatric disorders, – Schizophrenia – Personality disorders – ADHD,PTSD Common Addictions in DD Substance Addictions Alcoholism Street drug addiction Prescribed drug addiction Behavioural Addictions Gambling addiction Sex addiction Food addiction DSM-IV Criteria for Depression • • • depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains. Contd. • insomnia or hypersomnia nearly every day • psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) • fatigue or loss of energy nearly every day • feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) • diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) • recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide DSM-IV Diagnostic Criteria for Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following and occurring at any time in the same 12month period, 1) a) b) 2) a) b) Tolerance, as defined by either of the following: a need for markedly increased amount of the substance to achieve intoxication or desired effect; markedly diminished effect with continued use of the same amount of the substance. Withdrawal, as manifested by either of the following: the characteristic withdrawal syndrome for the substance the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. 1. The substance is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 3. A great deal of time is spent in activities necessary obtain the substance, use the substance, or recover from its effects. 4. Important social, occupational or recreational activities are given up or reduced because of substance use. 5. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. e.g. Unclear thinking, irritability, sleep problems, loss of interest, social withdrawal N.B. - Progressive Loss of Control & Damage in all areas Significant distress Assessment of Dual Diagnosis The possible relationships between addictions and psychiatric symptoms or disorders are the following: (according to McDowell & Spitz, 1999): 1. Primary Mental Illness Many psychiatric disorders can lead to symptoms associated with many addictions. Example: Depression Alcoholism Pathways: Self-soothing, self-medicating, selfdamage +? 2. Primary Addiction, including Withdrawal Symptoms: Many addictions can lead to symptoms associated with almost any psychiatric disorder. Example: Alcoholism Depression Pathways: Physiology, behaviour, cognition +? 3. Simultaneous and independent conditions. One disorder may prompt the emergence of the other, or the two disorders may exist independently. Example: History of Depression (inc. family) History of Alcoholism (inc. family) Interaction pathways as above Clues to Primary Problem (not always clear) • Began before serious secondary problem • Persists during remission periods of secondary problem • Severity of symptoms in relation to moderate levels of secondary problem • Chronic, acute, uniqueness of symptoms • Family history Approaches… Person-Centred: •Necessary but not sufficient •Doesn’t invalidate diagnostic categories Case Formulation, including Common Factors/Themes: •Common Mood Issues •Common Motivational Issues •Common Cognitive & Behavioural Issues Alcohol Dependence & Depression Themes of Mood/Reward, Motivation, Cognition, Behaviour Issue Depression Alcoholism Mood Low Low + mood shifts Expectation of Reward Low High Experience of Reward Low Decreasing Motivation for change Low Ambivalent Self-belief Low Low Negativity re future High High Social withdrawal High Progressive Self-care Low Low Sciacca etc: Motivational Interviewing + Cogntive Behavioural Therapy www.dualdiagnosis.ie http://users.erols.com/ksciacca http://integrativecbt.blogspot.com Cycle of Change CBT Symptom Cycle Thoughts Emotions Behaviour Physiology TYPES OF DISTORTED THINKING 1. All-or-nothing thinking: You look at things in absolute, black-and-white categories. 2. Overgeneralization: You view a negative event as a never-ending pattern of defeat. 3. Mental filter: You dwell on the negatives and ignore the positives. 4. Discounting the positives: You insist that your accomplishments or positive qualities "don't count.“ 5. Jumping to conclusions: (A) Mind reading: you assume that people are reacting negatively to you when there is no definite evidence for this; (B) Fortune-telling: you arbitrarily predict that things will turn out badly. 6. Magnification or minimization: You blow things up way out of proportion, or you shrink their importance inappropriately. 7. Emotional reasoning: You reason from how you feel: "I feel like an idiot, so I really must be one." Or "I don't feel like doing this, so I'll put it off.“ 8. Should statements: You criticize yourself or other people with "shoulds" etc. 9. Labeling: You identify with your shortcomings. Instead of saying, "I made a mistake," you tell yourself, "I'm an idiot," or "a fool," or "a loser.“ 10. Personalization and blame: You blame yourself for something you aren't entirely responsible for, or you blame other people and overlook ways that your own attitudes and behavior might be contributing to a problem.