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1、Addicted, Crazy or Both?Now What?Dual Diagnosis in the CD PatientMark Menestrina, MD, FASAMBrighton Hospital / SEMCAmmenestrinabrightonhospital.orgMichigan Judges MI 8/2011Part 1 (the “teaser”)n nAddiction Reviewn nClassification of Mental Disordersn nReview of Common Disordersn nAssociation of Ment
2、al Health Disorders with SUDsPart 2n nReview of Selected Classes of Psychiatric Medicationsn nPharmacology for Recovery n nSafe Prescribing for Individuals with SUDsAddiction ReviewWE LIVE IN A MAGICAL THINKING MEDICATION SEEKING SOCIETYUSA is 4.7% of the World PopulationBut we consume almost 50% of
3、 the Worlds Drugs and most of the Worlds Pain MedicationMedia / TV / Radio flood us with messagesWe are taught not to tolerate any discomfort without taking something to feel betterADDICTION IS A BRAIN CHEMISTRY DISEASEn nInvolves theInvolves the Meso Meso-Limbic System (Primitive)-Limbic System (Pr
4、imitive)n nNeurotransmitter Mediated (Not Conscious)Neurotransmitter Mediated (Not Conscious)n nDenial is a Hallmark FeatureDenial is a Hallmark Featuren nEmotional, Physical, PsychologicalEmotional, Physical, Psychologicaln nChronic, Progressive, potentially FatalChronic, Progressive, potentially F
5、ataln nAffects Family, Community, Society and SchoolsAffects Family, Community, Society and Schoolsn n10% are susceptible to AddictionTreatable Disease10% are susceptible to AddictionTreatable Diseasen nDifferent than Abuse, anyone can Abuse Drugs or Different than Abuse, anyone can Abuse Drugs or A
6、lcohol.Preventable BehaviorAlcohol.Preventable BehaviorITS NOT REALLY A DISEASEIS IT?n n1956 AMA designates Alcoholism as a disease, 1956 AMA designates Alcoholism as a disease, Drug Addiction as a disease followedDrug Addiction as a disease followedn n“But you have a choice”“But you have a choice”n
7、 nLike depression 30 years ago, or oncology 40 Like depression 30 years ago, or oncology 40 years agoyears agon nCompare to other Chronic DiseasesCompare to other Chronic Diseasesn nWhen we do treat Addiction, we do so Acutely, When we do treat Addiction, we do so Acutely, and wonder why we have poo
8、r resultsand wonder why we have poor results12Can you find the (alleged) future alcoholic?LACK OF WILLPOWER?13IF ADDICTION / CHEMICAL DEPENDENCE IS TRULY A DISEASE.WHY DONT WE TREAT IT AS SUCH?Leading Causes of DeathData for the U.S. 2007Age 25-44Age 25-44InjuryInjuryCancerCancerHeart DiseaseHeart D
9、iseaseSuicideSuicideHomicideHomicideHIVHIVLiver DiseaseLiver DiseaseStrokeStrokeDiabetesDiabetesAge 15-24Age 15-24InjuryInjuryHomicideHomicideSuicideSuicideCancerCancerHeart DiseaseHeart DiseaseCongenital Congenital StrokeStrokeDiabetesDiabetesGoogle: Alcoholism + HumorADDICTION vs. ABUSEn nALCOHOLI
10、SM, ALCOHOLISM, DRUG ADDICTION, DRUG ADDICTION, CHEMICAL CHEMICAL DEPENDENCEDEPENDENCEn nA TREATABLE A TREATABLE DISEASEDISEASEn nDRUG ABUSE, DRUG ABUSE, ALCOHOL ABUSEALCOHOL ABUSEn nA PREVENTABLE A PREVENTABLE BEHAVIORBEHAVIORTHE NEW GATEWAY FOR MANY YOUNG PEOPLEADDICTION TREATMENT MADE EASY. “A” t
11、o “B” NEGATIVE NEGATIVE Consequences: The Consequences: The job, liver, judge, wife, job, liver, judge, wife, boss, friend get the boss, friend get the individuals attention!individuals attention! POSITIVE POSITIVE Reinforcement: The Reinforcement: The individual actually individual actually begins
12、to like and begins to like and enjoy “recovery”enjoy “recovery”While this process is achievable, it is not likely to all make sense to the patient. It may involve 12 step, counseling, treatment of co-morbid conditions, Medication Assisted Treatments and other modalities.HOW TO SPOT A HUNTER WITH A D
13、UI CONVICTION.Co-Occurring DisordersPsychiatric Illness & AddictionGeneralizationsBoth are common problemsBoth are common problemsHaving one increases the risk for having the otherHaving one increases the risk for having the otherHaving one complicates the treatment of the otherHaving one complicate
14、s the treatment of the other when both are present when both are present“Dual Diagnosis” cases are over represented “Dual Diagnosis” cases are over represented among homeless and incarcerated among homeless and incarcerated “Dual Diagnosis” have increased risk of HIV and“Dual Diagnosis” have increas
15、ed risk of HIV and other serious medical conditions other serious medical conditionsClassification of Mental DisordersDSM-IV-TR n nThe official classification system of psychiatric The official classification system of psychiatric conditions in use in the USAconditions in use in the USAn nCriteria i
16、n DSM are used to facilitate Criteria in DSM are used to facilitate communication among professionals, for research communication among professionals, for research standards, and for 3standards, and for 3rdrd party party payorpayor communication communicationn nDSM- A mental disorder is a disorder w
17、ith DSM- A mental disorder is a disorder with significant behavioral or psychological symptoms significant behavioral or psychological symptoms associated with present distress, disability or associated with present distress, disability or increased risk of suffering death, pain, disability or incre
18、ased risk of suffering death, pain, disability or loss of freedomloss of freedomTHE 5 AXES OF DSMn nI. CLINICAL DISORDERSI. CLINICAL DISORDERSn nII. PERSONALITY DISORDERS and II. PERSONALITY DISORDERS and MENTAL RETARDATION MENTAL RETARDATIONn nIII. GENERAL MEDICAL CONDITIONSIII. GENERAL MEDICAL CON
19、DITIONSn nIV. PSYCHOSOCIAL AND IV. PSYCHOSOCIAL AND ENVIORNMENTAL PROBLEMS ENVIORNMENTAL PROBLEMSn nV. GAF (Global Assessment of Functioning)V. GAF (Global Assessment of Functioning)ASAM DIMENSIONSI. ACUTE INTOXICATION OR I. ACUTE INTOXICATION OR WITHDRAWAL POTENTIAL WITHDRAWAL POTENTIALII. BIOMEDIC
20、AL CONDITIONSII. BIOMEDICAL CONDITIONSIII. EMOTIONAL, BEHAVIORAL OR III. EMOTIONAL, BEHAVIORAL OR COGNITIVE CONDITIONS COGNITIVE CONDITIONSIV. READINESS TO CHANGEIV. READINESS TO CHANGEV. RELAPSE POTENTIALV. RELAPSE POTENTIALVI. RECOVERY/LIVING ENVIORNMENTVI. RECOVERY/LIVING ENVIORNMENTDSM at Work(o
21、r not!)Major Depressive EpisodeA.A.Five (or more) of the following symptoms have Five (or more) of the following symptoms have been present during the same 2-week period and been present during the same 2-week period and represent a change from previous functioning; at represent a change from previo
22、us functioning; at least one of the symptoms is either (1) depressed least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly Note: Do not include symptoms that are clearly due
23、to a general medical condition, or mood-due to a general medical condition, or mood-incongruent delusions or hallucinationsincongruent delusions or hallucinationsMDcontinued (1) Depressed mood most of the day, nearly every (1) Depressed mood most of the day, nearly every day, as indicated by either
24、subjective report (e.g., day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by feels sad or empty) or observation made by others (e.g., appears tearful) Note: In children others (e.g., appears tearful) Note: In children and adolescents, can be irritable mood
25、.and adolescents, can be irritable mood. (2) Markedly diminished interest or pleasure in (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly all, or almost all, activities most of the day, nearly every day (as indicated by either subjective every da
26、y (as indicated by either subjective account or observation made by others)account or observation made by others)MDcontinued (3) Significant weight loss when not dieting or (3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of weight gain (e.g., a change of m
27、ore than 5% of body weight in a month), or decrease or increase in body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, appetite nearly every day. Note: In children, consider failure to make expected weight gains.consider failure to make expected weight g
28、ains. (4) Insomnia or (4) Insomnia or hypersomniahypersomnia nearly every day nearly every day (5) Psychomotor agitation or retardation nearly (5) Psychomotor agitation or retardation nearly every day (observable by others, not merely every day (observable by others, not merely subjective feelings o
29、f restlessness or being slowed subjective feelings of restlessness or being slowed down)down)MDcontinued (6) Fatigue or loss of energy nearly every day (6) Fatigue or loss of energy nearly every day (7) Feelings of worthlessness or excessive or (7) Feelings of worthlessness or excessive or inappropr
30、iate guilt (which may be delusional) inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt nearly every day (not merely self-reproach or guilt about being sick)about being sick) (8) Diminished ability to think or concentrate, or (8) Diminished ability to t
31、hink or concentrate, or indecisiveness, nearly every day (either by indecisiveness, nearly every day (either by subjective account or as observed by otherssubjective account or as observed by othersMDcontinued (9) Recurrent thoughts of death (not just fear of (9) Recurrent thoughts of death (not jus
32、t fear of dying), recurrent suicidal ideation without a dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific specific plan, or a suicide attempt or a specific plan for committing suicide.plan for committing suicide.B.B.The symptoms do not meet criteria for
33、a Mixed The symptoms do not meet criteria for a Mixed Episode (see p. 171)Episode (see p. 171)C.C.The symptoms cause clinically significant The symptoms cause clinically significant distress or impairment in social, occupational, or distress or impairment in social, occupational, or other important
34、areas of functioning.other important areas of functioning.MDcontinuedD.D.The symptoms are not due to the direct The symptoms are not due to the direct physiological effects of a substance (e.g., a drug physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical of
35、 abuse, a medication) or a general medical condition (e.g., hypothyroidism)condition (e.g., hypothyroidism)E.E.The symptoms are not better accounted for by The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, Bereavement, i.e., after the loss of a loved one,
36、 the symptoms persist for longer than 2 months or the symptoms persist for longer than 2 months or are characterized by marked functional are characterized by marked functional impairment, morbid preoccupation with impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic wor
37、thlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.symptoms, or psychomotor retardation.MDdiagnosis in the real worldn nDepressed mood plus.Depressed mood plus.S sleep disturbanceS sleep disturbanceI loss of interest or pleasure (I loss of interest or pleasure (anhedoniaan
38、hedonia) )G feelings of guilt or worthlessnessG feelings of guilt or worthlessnessE low energyE low energyC poor concentration or memoryC poor concentration or memoryA appetite disturbanceA appetite disturbanceP psychomotor agitation or retardationP psychomotor agitation or retardationS suicidal ide
39、ationS suicidal ideationREMEMBER THAT DSM CRITERIA ARE HELPFUL GUIDELINES.BUT WE ALL HAVE A LITTLE (OR A LOT) IN EACH OF US!REVIEW OF COMMON DISORDERSn nSCHIZOPHRENIAn nAFFECTIVE DISORDERSn nANXIETY DISORDERS (including PTSD)n nPERSONALITY DISORDERSn nATTENTION DEFICIT HYPERACTIVITYn nEATING DISORDE
40、RSn nSUBSTANCE RELATED DISORDERSSCHIZOPHRENIAn nComplex illness, characterized by hallucinations, Complex illness, characterized by hallucinations, delusions, behavioral disturbances, disrupted delusions, behavioral disturbances, disrupted social functioning, disorganized speech and social functioni
41、ng, disorganized speech and negative symptomsnegative symptomsn n0.5-1% Prevalence0.5-1% Prevalencen nViolent acts no more frequent than the general Violent acts no more frequent than the general populationpopulationn nReduced life expectancy, 40% attempt suicide, 10-Reduced life expectancy, 40% att
42、empt suicide, 10-20% succeed 20% succeed n nTreatment antipsychotic medicationsTreatment antipsychotic medicationsAFFECTIVE DISORDERS MOOD DISORDERSn nDEPRESSION: common, often missed, not hard to diagnose when you look for it, often severe, often recurrent, costly and highly treatablen nBIPOLAR DIS
43、ORDERS Depression with episodes of elevated mood BIPOLAR I= with at least one manic episode BIPOLAR II= with hypomanic episodesAffective DisordersDIAGNOSISDIAGNOSISCRITERIACRITERIAMDDMDDSevere Severe SxSx, 5 , 5 SxSx, 2 Wks, 2 WksDYSTHYMIADYSTHYMIALess severe, more Less severe, more persistentpersis
44、tentBIPOLAR IBIPOLAR IMania and DepressionMania and DepressionBIPOLAR IIBIPOLAR IIHypomania, Depression?Hypomania, Depression?CYCLOTHYMIACYCLOTHYMIALess severe, more Less severe, more persistentpersistentSUBSTANCE-SUBSTANCE-INDUCEDINDUCEDConsequence of Use or Consequence of Use or w/dw/dANXIETY DISO
45、RDERSn nGENERALIZED ANXIETY DISORDERn nSOCIAL PHOBIAn nSIMPLE PHOBIASn nPANIC DISORDERn nAGORAPHOBIAn nPTSDPERSONALITY DISORDERSCLUSTERCLUSTERDESCRIPTIONDESCRIPTIONDISORDERSDISORDERSA AOdd/EccentricOdd/EccentricParanoid/Schizoid/Paranoid/Schizoid/SchizotypalSchizotypalB BDramatic/ErraticDramatic/Err
46、aticAntisocial/Borderline/Antisocial/Borderline/Histrionic/NarcissisticHistrionic/NarcissisticC CAnxious/FearfulAnxious/FearfulAvoidant/Dependent/Avoidant/Dependent/Obsessive-CompulsiveObsessive-CompulsiveADHDn nInattention, hyperactivity, impulsivityn nADHD does associate with higher risk for SUDs,
47、 but this may be limited to those with coexisting conduct or bipolar disordern nTreating ADHD with stimulants actually appears to be associated with a decreased risk of developing a subsequent SUDEATING DISORDERSn nANOREXIA: often severely restrict caloric intake ANOREXIA: often severely restrict ca
48、loric intake or excessively exercise, are underweightor excessively exercise, are underweightn nBULEMIA: often alternate eating with starvation BULEMIA: often alternate eating with starvation or purging, are usually normal weightor purging, are usually normal weightn nBoth groups may abuse appetite
49、suppressants, Both groups may abuse appetite suppressants, diuretics or laxativesdiuretics or laxativesn nBULEMICS appear to be at risk for BULEMICS appear to be at risk for SUDsSUDsn nOne study found ANOREXICS to be at lower risk One study found ANOREXICS to be at lower risk for for SUDsSUDsSUBSTAN
50、CE INDUCED DISORDERSn nThese disorders mimic other psychiatric disorders, but they are in fact caused, directly or indirectly, by use of substancesn nThis is a tremendous source of misdiagnosis, and results in ineffective treatment of the substance disordern nWe live in a society where it is more so
51、cially acceptable to be mentally ill than chemically dependentDiagnoses Associated with Class of Substances.DSM-IV-TRDependDependAbuseAbuseIntoxIntoxW/DW/DAlcoholAlcohol+ + + + +AmphetaminesAmphetamines+ + + + +CannabisCannabis+ + + +CocaineCocaine+ + + + +OpioidsOpioids+ + + + +SedativesSedatives+
52、+ + + +Substance Induced Mental DisordersOrganic Brain SyndromesOrganic Brain Syndromes SI Delirium SI Delirium SI Persisting Dementia SI Persisting Dementia SI SI AmnesticAmnestic Disorder DisorderMimic Axis I DisordersMimic Axis I Disorders SI Psychotic Disorder SI Psychotic Disorder SI Mood Disor
53、der SI Mood Disorder SI Anxiety Disorder SI Anxiety Disordern nHallucinogen Hallucinogen Persisting Perceptual Persisting Perceptual DisorderDisordern nSI Sexual DysfunctionSI Sexual Dysfunctionn nSI Sleep DisorderSI Sleep DisorderASSOCIATION OF MENTAL DISORDERS WITH SUDsSUDs includeADDICTION: a tre
54、atable diseaseABUSE: a preventable behavior2003 National Survey of Drug Use and Health (NSDUH)n n21.3% of Adults with Serious Mental Illness (SMI) had a Substance Use Disorder (SUD)n n7.9% of Adults without SMI had a SUDNicotine and Mental IllnessGrant, B.F. et al, 200412 MONTH 12 MONTH PREVALENCEPR
55、EVALENCEODDS RATIOODDS RATIOMOOD MOOD DISORDERDISORDER21%21%3.33.3ANXIETY ANXIETY DISORDERDISORDER22%22%2.72.7PERSONALITY PERSONALITY DISORDERDISORDER32%32%3.33.3Serious Mental Illness and Its Co-Occurrence with Substance Use Disorders, 2002Epstein, Barker, Vorburger and Murtha, 2004SAMHSA.GOV17.5 m
56、illion Adults with SMI (Serious Mental Illness) 8.3% of populationn n18-25yo 13.2%18-25yo 13.2%n n26-49yo 9.5%26-49yo 9.5%n n50yo 4.9%50yo 4.9%n nFemale 10.5%Female 10.5%n nMale 6.0%Male 6.0%n n1 race 13.6%1 race 13.6%n nNat Am 12.5%Nat Am 12.5%n n28.9% used illicit drug/yr28.9% used illicit drug/yr
57、n nIllicit drug/yr 17.1%Illicit drug/yr 17.1%n nNo drug/yr 6.9%No drug/yr 6.9%n nSMI did not vary by past SMI did not vary by past year alcohol useyear alcohol usen n Heavy” alcohol/mo 11.1%Heavy” alcohol/mo 11.1%n nvs. 8.1% vs. 8.1% Co-Occurrence of SMI & SUD33.2 million SMI or SUD33.2 million SMI
58、or SUD 13.4 million (40.4%) SMI 13.4 million (40.4%) SMI 15.5 million (47.4%) SUD 15.5 million (47.4%) SUD 4.0 million (12.2%) SMI + SUD 4.0 million (12.2%) SMI + SUD Both Disorders: 23.2% of SMI Both Disorders: 23.2% of SMI 20.4% of SUD 20.4% of SUD Rates of SMI.Without any SUDWithout any SUD7.0%7.
59、0%Alcohol Dependence or AbuseAlcohol Dependence or Abuse19.0%19.0%Illicit Drug Dependence or AbuseIllicit Drug Dependence or Abuse29.1%29.1%Alcohol and Drug Use DisorderAlcohol and Drug Use Disorder30.1%30.1%Lifetime SUD Among Persons with Mental Disorders.Regier et al, 1990MENTAL MENTAL DISORDERDIS
60、ORDERLIFETIMELIFETIMEPREVPREVLIFETIMELIFETIMEPREV SUDPREV SUDODDS ODDS RATIORATIOschizophreniaschizophrenia1.5%1.5%47.0%47.0%4.64.6antisocial p.d.antisocial p.d.2.6%2.6%83.6%83.6%29.629.6anxiety disordersanxiety disorders14.6%14.6%23.7%23.7%1.71.7OCDOCD2.5%2.5%32.8%32.8%2.52.5affective disordersaffe
61、ctive disorders8.3%8.3%32.0%32.0%2.62.6any disorderany disorder16.2%16.2%28.9%28.9%2.72.7Why the Association?n nCommon Risk Factors & Etiologies, genetic or environmentaln nAddiction might lead to Mental Illnessn nPsychiatric Illness might lead to Addictionthe “Self-Treating Hypothesis”n nSelf-Limit
62、ing Acute Effects of a Substance (or withdrawal from it) may be mistaken for a psychiatric illnessAffective DisordersAssociation with SUD Regier et.al. 1990SMISMISUDSUDODDS RATIOODDS RATIOAny Affective Any Affective AlcoholAlcohol1.91.9Any Affective Any Affective CocaineCocaine5.95.9Any Affective An
63、y Affective OpiatesOpiates5.05.0Any Affective Any Affective BarbituratesBarbiturates6.66.6Any Affective Any Affective HallucinogensHallucinogens5.95.9Bipolar DisorderBipolar DisorderAny SUDAny SUD6.66.6UnipolarUnipolar d/o d/oAny SUDAny SUD1.91.9Summary Pointsn nCo-Occurring Disorders are CommonCo-O
64、ccurring Disorders are Commonn nMay be difficult to differentiate from Substance May be difficult to differentiate from Substance Induced DisordersInduced Disordersn nConsider “Watchful Waiting” in less definite cases Consider “Watchful Waiting” in less definite cases when degree of impairment is no
65、t as severewhen degree of impairment is not as severen nTreatment is often ChallengingTreatment is often Challengingn nBoth Disorders need to be addressed when both Both Disorders need to be addressed when both are truly presentare truly presentn nMay be “Road Blocked” by Insurance/Funding May be “Road Blocked” by Insurance/Funding SourcesSources“NEVER DOUBT THAT A SMALL GROUP OF DEDICATED CITIZENS CAN CHANGE THE WORLDINDEED IT IS THE ONLY THING THAT EVER HAS”Margaret MeadeMargaret Meade
