Download Co-occurring Disorders The Mix of Meds and Therapy

Co-occurring Disorders
The Mix of Meds and Therapy
Illinois Department of Human Services
Cross Divisional Training
February 19, 2008
Seth Eisenberg MD
About Me
• Psychiatric Residency in San Francisco
• Child Psychiatry--Adolescent CD
• Community Mental Health, Marin
County Jail-- De-Institutionalization
• Hawaii—Adol. CD, private sector (ice)
• Charter Hospital NW Indiana (PG),
• Interventions, WTC, MPG, CAP, TASC
• DASA medical director
• Northwestern—fellowship, in-patient
Co-occurring Disorders
The Mix of Meds and Therapy
Agenda Topics
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Working with COD—Attitudes of Clinicians
Meds for Anxiety and Mood Disorders
Medication Treatment—General Principles
Integrated Tx for Anxiety and Alcohol
Talking to Patients about Medications
“Skeptical Attunement”
DUAL DIAGNOSIS
Complications of Comorbidity
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Increased Severity of Symptoms
Increased Psychiatric Hospitalization
Increased Use of Emergency Services
Increased Violent and Suicidal Behavior
DUAL DIAGNOSIS
Poor Psychosocial Adjustment
• Increased Homelessness
• Increased Unemployment
• Increased Vocational Disability
• Lack of Social Support Systems
• Earlier Age of Onset
• Treatment Chronicity
Attitudes and Values for
Clinicians
• Patience, perseverance, and therapeutic
optimism
• Ability to employ diverse theories,
concepts, models and methods
• Flexibility of approach
• Cultural competence
• Belief that all individuals have strengths
and are capable of growth and
development
Six Guiding Principles in Treating
Clients with COD
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Employ a recover perspective
Adopt a multi-problem viewpoint
Develop a phased approach to treatment
Address specific real-life problems early in
treatment
5. Plan for the client’s cognitive and
functional impairments
6. Use support systems to maintain and
extend treatment effectiveness
Recovery Perspective
• Assess clients stage of change
• Treatment stage (or expectations) should
be consistent with stage of change
• Use client empowerment to enhance
motivation
• Foster continuous support
• Provide continuity of treatment
• Recognize that recovery is a long-term
process and support small gains
Therapeutic Alliance
• Demonstrate understanding and acceptance
• Help client clarify nature of the difficulty
• Indicate you and client will be working
together
• You will be helping client help themselves
• Express empathy and willingness to listen to
the clients view of the problem
• Assist client to solve some external
problems directly and immediately
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
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
Successful Therapeutic Relationships
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Use a therapeutic alliance to engage
Maintain a recovery perspective
Use supportive and empathic counseling
Manage countertransference
Monitor psychiatric and SUD symptoms
Employ culturally appropriate methods
Increase structure and support
Anxiety Disorders and SUD
Prevalence
• 18% with SUD--at least one anxiety disorder
• 15% with AD had at least one SUD
• Treatment seekers for AUD—23-69% w AD
• Treatment seekers for SUD—50% w AD
• Treatment seekers for AD—12% w AUD
• Treatment seekers for AD—7% w SUD
Clear need for cross discipline screen,
assessment and treatment
Anxiety Disorders and SUD
Explanatory Models
• Secondary substance use model
– Self medication: substance interacts with
psychiatric disturbance to make use compelling
in susceptible individuals
– Ongoing use leads to development of SUD
• Secondary psychopathology model—SUD
leads to the development of psychiatric d/o
– Substance use may sensitize neurobiological
stress systems and lead to higher level of
vulnerability to PTSD systems after trauma
Anxiety Disorders and SUD
Explanatory Models
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Common factor model
– underlying genetic or physiologic liability
– anxiety sensitivity: tendency to interpret
feelings of anxiety as dangerous
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Bi-directional model
– Both the SUD and anxiety disorder play a
role in either developing or maintaining each
other
– Social phobic uses alcohol, develops more
problems, increased anxiety and more ETOH
Anxiety Disorders and SUD
Explanatory Models
• Self Medication Hypothesis
– People with anxiety and SUD would report
that they use substances to manage anxiety
– People with more severe anxiety would be at
increased risk for SUD
– Anxiety would precede substance use
– Substances used by people with anxiety and
SUD would be anxiolytic
Panic Attack
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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
Panic Disorder
“The presence of recurrent, unexpected panic
attacks followed by persistent concern about
having another panic attack.” (DSM IV)
 1.5% - 3.5% Lifetime prevalence
Panic attacks may be induced by
substance use
 With or without agoraphobia
 TCAs and SSRIs
Block panic attacks
Start with low doses
 Latency of onset - use of benzodiazepines
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
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
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
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
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
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
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Restlessness or feeling keyed up, on edge
Easily fatigued,
Irritability
difficulty concentrating or mind going blank
Muscle tension
Sleep disturbance
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)
• SSRI, TCA, venlafaxine, anticonvulsants
• Use of benzodiazepines is controversial
• Buspirone may be effective
Mood Disorders
• Depressive Disorders
– Major Depressive Disorder
– Dysthymic Disorder
• BiPolar Disorders
– Bipolar I
– Bipolar II
• Cyclothymic Disorder
• Substance Induced Mood Disorder
Affective Illness and CD
1. Convincing history of affective
disorder previously diagnosed,
ideally during abstinence, with
historical indications of expected
medication response if medicated.
2. Depression is a normal feeling
state in early sobriety.
3. Mania must be distinguished from
anxiety and chronic ADHD.
Affective Illness and CD
(continued)
4. Positive family history is
suggestive.
5. Seek historical evidence of
episodic mood alterations that
last for weeks/months and are
independent of events.
Depressive Disorders and CD
• 5% - 25% up to 90%
• Varied time for improvement based
on substance
• Depression part of recovery process
• Abuse of TCAs in methadone clinics,
elevated blood levels
• Activating effect, cardiotoxicity
• SSRIs better tolerated, safer,
decreased drinking
Medications for Bipolar and SUD
• Bipolar with SUD—56% (ECA), most
common Axis I
• SUD assoc. w poor prognosis in Bipolar
– More hospitalizations for affective episodes
– Affective sx earlier in life
– More depressive or mixed episodes
• COD w increased time to med treatment
• Increased risk for antidepressant induced
mania
Medications for Bipolar and SUD
• Lithium may be less effective in COD
– May be useful in adolescents with COD
• More responsive to anticonvulsants
– “Kindling”—neuronal sensitization in alcohol
withdrawal and cocaine intoxication
– Valproate (may also decreased drinking)
– Carbamazepine (helpful with cocaine)
– Generally safe—monitor liver and blood count
• topiramate helpful in alcohol dependence
Medications for Bipolar and SUD
• lamotragine—helped with cocaine
• Gabapentin—may help with alcohol/anxiety
• Atypical antipsychotics
– Seroquel—mood, alcohol, anxiety
– others
Ask the Doc
Medication Treatment of
Psychiatric and Substance Use
Disorders
Psychotherapeutic Medications: What
Every Counselor Should Know
Mid-America Addictions Technology Transfer Center
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
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
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)
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
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
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
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
under-medicating
• Different treatments should be
complementary, not competitive
Which to treat first: Comorbid
anxiety or alcohol disorder?
Current Psychiatry
Vol. 6 No.8/Aug 2007
Kushner, et al.
Comorbid Anxiety and Alcohol
Which Comes First?
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)
• SSRI, TCA, venlafaxine, anticonvulsants
• Use of benzodiazepines is controversial
• Buspirone may be effective
Comorbid Anxiety and Alcohol
Which Comes First?
• Risk of getting new ETOH Dep as a Jr/Sr
more that 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
Comorbid Anxiety and Alcohol
Treatment Approaches
• Serial (sequential) approach—treatment
comorbid disorders one at a time
• Parallel approach—providing simultaneous
but separate treatments for each
comorbidity
• Integrated approach—providing one
treatment that focuses on both comorbid
disorders, especially as they interact with
one another
• Tx determined by clinical and resources
Comorbid Anxiety and Alcohol
Treatment Approaches
Serial Treatment—treat disorder one at a time
• May help empirically evaluate whether the
untreated condition is resolved by treating other
• Allows use of established treatment resources
• Initially untreated comorbid disorder could
undermine resolution of the treated disorder.
• Not always clear which disorder to treat first—may
depend on presenting symptom
• Tx with meds for anxiety and then address ETOH
with brief intervention
Comorbid Anxiety and Alcohol
Treatment Approaches
Parallel Treatment—simultaneous/separate
• may be less common in MH settings
• Requires coordination of clinicians, tx
strategies, times, locations
• Impact of other disorder not appreciated
• MH vs SUD treatment programs may have
conflicting values
Comorbid Anxiety and Alcohol
Treatment Approaches
Integrated Treatment—one treatment plan
(or one tx) for both disorders (not many)
• CBT-based integrated approach
– Psychoeducation
– Cognitive restructuring
– Cue exposure
Comorbid Anxiety and Alcohol
CBT-based integrated approach
Psychoeducation—explain biopsychosocial
model of anxiety/alcohol disorders
• Basic epidemiology
• Negative interactions between the two
• Introduce role of cognitions, thoughts,
beliefs and expectations
• Teach diaphragmatic breathing to reduce
hyperventilation
Comorbid Anxiety and Alcohol
CBT-based integrated approach
Cognitive restructuring—(req.CBT skills)
• Thinking patterns that contribute to
initiating and maintaining anxiety and
panic
• Recognized and restructure thinking that
promotes alcohol use to cope w anxiety
Comorbid Anxiety and Alcohol
CBT-based integrated approach
Cue exposure—therapist guided exposure
to fear provoking situations and sensations
to decouple from anxiety and catastrophe
• Helps with reality testing
• Practice for anxiety management skills
• Enhance self-efficacy
Comorbid Anxiety and Alcohol
CBT-based integrated approach
• Exposures (imaginal and in vivo) expanded to
include alcohol–relevant cues assoc. with anxiety
states to decouple self-medication and practice
other coping skills
CONCLUSION: Effects of Integrated CBT TX for
comorbid panic and alcohol disorders was more
effective for patients with the strongest for
patients with strongest expectations that alcohol
helps control their anxiety
Talking to Patients about Medications
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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.
Medication Adherence
Comorbid SUD a Risk Factor 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
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
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
Psychotherapy for Patients with
Co-occurring Disorders
“Skeptical Attunement:
Modifying Psychodynamic Technique for
Substance Abuse Treatment”
Karen Frieder, PhD
Roy Futterman, PhD
Susan Silverman, PhD
Psychotherapy for DDX
“Skeptical Attunement”
Skeptical attunement is the use of
healthy skepticism as a means of
confronting the patient in a way that is
experienced as empathic attunement,
leading to more meaningful work.
Psychotherapy for DDX
“Skeptical Attunement”
• Psychodynamic technique can fill a gap in
current addiction treatment by addressing the
emotional discomfort and disconnection that
underlies a great deal of substance use.
• Model of psychodynamic work that will help to
focus on patients’ emotional lives, their specific
substance abuse behaviors and will make
explicit the connections
• Help patients gain control over their substance
use as well as their emotional lives.
Psychotherapy for DDX
“Skeptical Attunement”
Historical Context
• Addiction a symptom of underlying
psychopathology
• Standard analytic technique without
directly addressing substance use
• Others felt Tx not appropriate until sober
or that patients were unanalyzable
Psychotherapy for DDX
“Skeptical Attunement”
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Historical Context
AA felt psychology had little to offer
12 Step, TCs, Self help, abstinence
May have been anti-psychiatric care
Patients in denial, not ready, haven’t hit
bottom
Psychotherapy for DDX
“Skeptical Attunement”
Recent advances in psychotherapy for
addiction treatment
– Relapse Prevention
– Harm Reduction
– Motivational Interviewing
Psychotherapy for DDX
“Skeptical Attunement”
Relapse Prevention
– Assumes relapse a natural and predictable
part of the recovery process
– Discuss and learn from each relapse to
prevent future relapses
– CBT Function analysis
– Relapse is not random and patients can learn
the patterns
Psychotherapy for DDX
“Skeptical Attunement”
• Harm Reduction
– Patients accepted into treatment with various
levels of substance use
– Abstinence not a mandated goal or
prerequisite
– Practitioner seeks to reduce the negative
impact of substance use on patients
– Similar to psychiatric treatment in that patients
are treated in individualized manner
Psychotherapy for DDX
“Skeptical Attunement”
Motivational Interviewing
– Stages of change, change is a process
– Different interventions for different stages
– Patients ambivalence about use is normal
– Enhance discrepancy
– Therapist role to increase client motivation
Join with clients to gain insight and
understanding to gain more control
Psychotherapy for DDX
“Skeptical Attunement”
Self Medication Theory: Patients use drugs
to self-medicate intolerable emotions
– Undiagnosed, untreated psychiatric illness
– Grief and trauma
– Difficulty regulating emotions
– Disconnected from and unaware of emotions
– Poor interpersonal skills and relationships
Psychotherapy for DDX
“Skeptical Attunement”
Modified Psychodynamic Technique: Goal to
increase awareness, make the unconscious
conscious and connect emotional life to
using behaviors
– Clinician more active and symptom focused
– Asking about use, risky situations, triggers
– Use of psychoeducation
– More transparent and genuine
– Discuss countertransference and skepticism
Psychotherapy for DDX
“Skeptical Attunement”
Working with Defenses
– Main defense is to use. Also denial,
displacement, dissociation, intellectualization
– Keeping “on the run” physically, interpersonally
– Defense against what?
– relate defenses to thoughts and emotions
which lead to urges and relapse
– Talking about it (to gain insight) will lead to
mastery
Psychotherapy for DDX
“Skeptical Attunement”
Talking about Cravings and Triggers
– Client reluctance to disclose: illegal, cause
them trouble, secret, weakness, guilty, shame,
other associated bad behaviors
– Therapist: non-judgmental and more active
– Deny cravings
– Mistake withdrawal for cravings and cravings
for withdrawal
Psychotherapy for DDX
“Skeptical Attunement”
Talking about Cravings and Triggers
– Behavioral patterns to cravings—People
places and things
– Stress and emotions (negative and positive)
– Mindfulness to physical and emotional self
– Connection to behavior—before and after
– Craving itself is short lived
– Working with dreams
Psychotherapy for DDX
“Skeptical Attunement”
Talking about Cravings and Triggers
– Recognizing and labeling to stop a relapse
– Sensitivity to transitions
– Pleasures, meanings and role of use (further
insight into triggers, losses and needs)
– Fulfillment of rituals and excitement
– Sexuality and intimacy
Psychotherapy for DDX
“Skeptical Attunement”
Skeptical Attunement: Any break from the
norm should be assumed by the clinician to
be related to relapse—there may be
numerous signs and symptoms
– clinician may point out changes and predict a
relapse (if before the relapse)
– ask pointed questions about what’s happening
– reference observations or recent behavior
Psychotherapy for DDX
“Skeptical Attunement”
Skeptical Attunement:
– Contrast current to more usual behavior
– Matter of fact attitude, assumption of relapse
– Straightforward but not accusatory
– May make disclosure more easy (or patient can
refute it)
– Clients experience this as attunement; don’t
want a clinician who is overly trusting and naïve
– Not attacking, not ignoring, “tuned in”
– May help with clinician countertransference
Psychotherapy for DDX
“Skeptical Attunement”
Countertransference
• Anticipate being lied to, manipulated, misused
(attenuated with skeptical attunement and directly
addressing behaviors and observations)
• Ineffectual, suspicious punitive interrogator
(awareness of need for and origins of secretiveness)
• Hurt, disappointed and angry with relapse
(attenuated with harm reduction and relapse prev)
• Need to be seen as street savey (reflect w truth)
• “Are you in recovery?” (explore but answer)