Co-occurring Disorders The Mix of Meds and Therapy

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Co-occurring DisordersThe Mix of Meds and Therapy

• Illinois Department of Human Services
• Cross Divisional Training
• February 19, 2008
• Seth Eisenberg MD

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About Me

• Psychiatric Residency in San Francisco
• Child Psychiatry--Adolescent CD
• Community Mental Health, Marin County Jail--
  De-Institutionalization
• HawaiiAdol. CD, private sector (ice)
• Charter Hospital NW Indiana (PG),
• Interventions, WTC, MPG, CAP, TASC
• DASA medical director
• Northwesternfellowship, in-patient

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Co-occurring DisordersThe Mix of Meds and
TherapyAgenda Topics

• Working with CODAttitudes of Clinicians
• Meds for Anxiety and Mood Disorders
• Medication TreatmentGeneral Principles
• Integrated Tx for Anxiety and Alcohol
• Talking to Patients about Medications
• Skeptical Attunement

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DUAL DIAGNOSIS Complications of Comorbidity

• Increased Severity of Symptoms
• Increased Psychiatric Hospitalization
• Increased Use of Emergency Services
• Increased Violent and Suicidal Behavior

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DUAL DIAGNOSIS Poor Psychosocial Adjustment

• Increased Homelessness
• Increased Unemployment
• Increased Vocational Disability
• Lack of Social Support Systems
• Earlier Age of Onset
• Treatment Chronicity

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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

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Six Guiding Principles in Treating Clients with
COD

• Employ a recover perspective
• Adopt a multi-problem viewpoint
• Develop a phased approach to treatment
• Address specific real-life problems early in
  treatment
• Plan for the clients cognitive and functional
  impairments
• Use support systems to maintain and extend
  treatment effectiveness

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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

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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

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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

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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 clients
• Provides support throughout the recovery process

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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

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Anxiety Disorders and SUDPrevalence

• 18 with SUD--at least one anxiety disorder
• 15 with AD had at least one SUD
• Treatment seekers for AUD23-69 w AD
• Treatment seekers for SUD50 w AD
• Treatment seekers for AD12 w AUD
• Treatment seekers for AD7 w SUD
• Clear need for cross discipline screen,
  assessment and treatment

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Anxiety Disorders and SUDExplanatory 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 modelSUD 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

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Anxiety Disorders and SUDExplanatory 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

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Anxiety Disorders and SUDExplanatory 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

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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

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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
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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

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Anxiety Disorders and SUDMedication 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 relapseuse low dose
  initiation
• Latency of onset of effect, 2-6 weeks
• SSRIsno abuse potential, safe, generally well
  tolerated, may help with ETOH

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Anxiety Disorders and SUDMedication 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

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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

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Anxiety Disorders and SUDMedication 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

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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

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Anxiety Disorders and SUDMedication Treatment

• Generalized Anxiety Disorder (8-52 in AUD, 21
  in MMT, 8 in cocaine)
• Diagnostic difficultiesoverlap 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

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Mood Disorders

• Depressive Disorders
• Major Depressive Disorder
• Dysthymic Disorder
• BiPolar Disorders
• Bipolar I
• Bipolar II
• Cyclothymic Disorder
• Substance Induced Mood Disorder

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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.
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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.
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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

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Medications for Bipolar and SUD

• Bipolar with SUD56 (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

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Medications for Bipolar and SUD

• Lithium may be less effective in COD
• May be useful in adolescents with COD
• More responsive to anticonvulsants
• Kindlingneuronal sensitization in alcohol
  withdrawal and cocaine intoxication
• Valproate (may also decreased drinking)
• Carbamazepine (helpful with cocaine)
• Generally safemonitor liver and blood count
• topiramate helpful in alcohol dependence

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Medications for Bipolar and SUD

• lamotraginehelped with cocaine
• Gabapentinmay help with alcohol/anxiety
• Atypical antipsychotics
• Seroquelmood, alcohol, anxiety
• others

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Ask the Doc
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Medication Treatment of Psychiatric and Substance
Use Disorders

• Psychotherapeutic Medications What Every
  Counselor Should Know
• Mid-America Addictions Technology Transfer Center

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Medication TreatmentGeneral Principles

• Pharmacologic effects
• Therapeuticindicated purpose and desired outcome
• Detrimentalunwanted side effects (may interfere
  with adherence), potential for abuse and
  addiction
• Need a balance between therapeutic and
  detrimental

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Medication TreatmentGeneral 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

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Medication TreatmentGeneral 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)

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Medication TreatmentGeneral Principles

• Positive reinforcementincrease 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

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Medication TreatmentStepwise 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

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Medication TreatmentStepwise Treatment Model

• High risk patients with anxiety disorder
• Non-pharmacologic approaches when possible
• Non-psychoactive medications added next as
  adjunctive treatment
• Psychoactive medications when other treatments
  fail

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Medication TreatmentStepwise 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

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Which to treat first Comorbid anxiety or alcohol
disorder?

• Current Psychiatry
• Vol. 6 No.8/Aug 2007
• Kushner, et al.

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Comorbid Anxiety and Alcohol Which Comes First?

• Generalized Anxiety Disorder (8-52 in AUD, 21
  in MMT, 8 in cocaine)
• Diagnostic difficultiesoverlap 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

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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

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Comorbid Anxiety and Alcohol Treatment Approaches

• Serial (sequential) approachtreatment comorbid
  disorders one at a time
• Parallel approachproviding simultaneous but
  separate treatments for each comorbidity
• Integrated approachproviding one treatment that
  focuses on both comorbid disorders, especially as
  they interact with one another
• Tx determined by clinical and resources

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Comorbid Anxiety and Alcohol Treatment Approaches

• Serial Treatmenttreat 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
  firstmay depend on presenting symptom
• Tx with meds for anxiety and then address ETOH
  with brief intervention

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Comorbid Anxiety and Alcohol Treatment Approaches

• Parallel Treatmentsimultaneous/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

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Comorbid Anxiety and Alcohol Treatment Approaches

• Integrated Treatmentone treatment plan (or one
  tx) for both disorders (not many)
• CBT-based integrated approach
• Psychoeducation
• Cognitive restructuring
• Cue exposure

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Comorbid Anxiety and Alcohol CBT-based
integrated approach

• Psychoeducationexplain 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

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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

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Comorbid Anxiety and Alcohol CBT-based
integrated approach

• Cue exposuretherapist 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

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Comorbid Anxiety and Alcohol CBT-based
integrated approach

• Exposures (imaginal and in vivo) expanded to
  include alcoholrelevant 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

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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.

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Medication AdherenceComorbid 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

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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

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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 dont like pills (or meds).
• Elicit a reasonnever needed it, cured now, dont
  believe in it, means Im crazy, side effects,
  afraid, shame, cost, interpersonal, want to be in
  control, do it on my own, cant use
• Motivational Interviewing

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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

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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.

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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.

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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

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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, havent hit bottom

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Psychotherapy for DDX Skeptical Attunement

• Recent advances in psychotherapy for addiction
  treatment
• Relapse Prevention
• Harm Reduction
• Motivational Interviewing

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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

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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

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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

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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

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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

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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

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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

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Psychotherapy for DDX Skeptical Attunement

• Talking about Cravings and Triggers
• Behavioral patterns to cravingsPeople places and
  things
• Stress and emotions (negative and positive)
• Mindfulness to physical and emotional self
• Connection to behaviorbefore and after
• Craving itself is short lived
• Working with dreams

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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

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Psychotherapy for DDX Skeptical Attunement

• Skeptical Attunement Any break from the norm
  should be assumed by the clinician to be related
  to relapsethere may be numerous signs and
  symptoms
• clinician may point out changes and predict a
  relapse (if before the relapse)
• ask pointed questions about whats happening
• reference observations or recent behavior

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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 dont want
  a clinician who is overly trusting and naïve
• Not attacking, not ignoring, tuned in
• May help with clinician countertransference

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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)