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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 • • • • • • 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 • • • • 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 1. 2. 3. 4. 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 • • • • • • • 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 • Common factor model – underlying genetic or physiologic liability – anxiety sensitivity: tendency to interpret feelings of anxiety as dangerous • 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 • • • • • • • • • 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 – – – – – – 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 • • • • 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” • • • • 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)