Helping the Dual Diagnosis Client

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• Helping the Dual Diagnosis Client
• Working with the complex relationships between
  addictions and mental health problems
• 6th May 2010

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• A person who has both a
• (substance) addiction problem and an
  emotional/psychiatric problem
• is said to have a dual diagnosis.
• The concept arises because addictions are not
  seen in the same way as other mental health
  problems addiction is often not thought of as a
  mental health problem.
• To recover fully, the person needs treatment for
  both problems.

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• Common MH Problems in DD
• Depressive disorders
• Depression
• Bipolar disorder
• Anxiety disorders
• Generalised anxiety disorder
• Panic disorder
• OCD
• Phobias
• Other psychiatric disorders,
• Schizophrenia
• Personality disorders
• ADHD,PTSD

Common Addictions in DD Substance Addictions -
Alcoholism - Street drug addiction - Prescribe
d drug addiction Behavioural Addictions - Gambli
ng addiction - Sex addiction - Food addiction
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DSM-IV Criteria for Depression

• depressed mood most of the day, nearly every day,
  as indicated by either subjective report (e.g.,
  feels sad or empty) or observation made by others
  (e.g., appears tearful). Note In children and
  adolescents, can be irritable mood.
• markedly diminished interest or pleasure in all,
  or almost all, activities most of the day, nearly
  every day (as indicated by either subjective
  account or observation made by others)
• significant weight loss when not dieting or
  weight gain (e.g., a change of more than 5 of
  body weight in a month), or decrease or increase
  in appetite nearly every day. Note in children,
  consider failure to make expected weight gains.

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Contd.

• insomnia or hypersomnia nearly every day
• psychomotor agitation or retardation nearly every
  day (observable by others, not merely subjective
  feelings of restlessness or being slowed down)
• fatigue or loss of energy nearly every day
• feelings of worthlessness or excessive or
  inappropriate guilt (which may be delusional)
  nearly every day (not merely self-reproach or
  guilt about being sick)
• diminished ability to think or concentrate, or
  indecisiveness, nearly every day (either by
  subjective account or as observed by others)
• recurrent thoughts of death (not just fear of
  dying), recurrent suicidal ideation without a
  specific plan, or a suicide attempt or a specific
  plan for committing suicide

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• DSM-IV Diagnostic Criteria for
• Substance Dependence
•   A maladaptive pattern of substance use, leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the following
  and occurring at any time in the same 12-month
  period,
•  1) Tolerance, as defined by either of the
  following
• a) a need for markedly increased amount of the
  substance to achieve intoxication or desired
  effect
• b) markedly diminished effect with continued
  use of the same amount of the substance.
• 2) Withdrawal, as manifested by either of the
  following
• a) the characteristic withdrawal syndrome for
  the substance
• b) the same (or a closely related) substance is
  taken to relieve or avoid withdrawal symptoms.

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• The substance is often taken in larger amounts or
  over a longer period than was intended.
•  There is a persistent desire or unsuccessful
  efforts to cut down or control substance use.
•  A great deal of time is spent in activities
  necessary obtain the substance, use the
  substance, or recover from its effects.
• Important social, occupational or recreational
  activities are given up or reduced because of
  substance use.
•   The substance use is continued despite
  knowledge of having a persistent or recurrent
  physical or psychological problem that is likely
  to have been caused or exacerbated by the
  substance.
• e.g. Unclear thinking, irritability, sleep
  problems, loss of interest, social withdrawal
• N.B. - Progressive Loss of Control Damage in
  all areas
• Significant distress

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Assessment of Dual Diagnosis

• The possible relationships
• between addictions
• and psychiatric symptoms or disorders
• are the following
• (according to McDowell Spitz, 1999)

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• Primary Mental Illness
• Many psychiatric disorders can lead to symptoms
  associated with many addictions.
• Example
• Depression Alcoholism
• Pathways Self-soothing, self-medicating,
  self-damage ?

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• Primary Addiction, including Withdrawal Symptoms
• Many addictions can lead to symptoms associated
  with almost any psychiatric disorder.
• Example Alcoholism Depression
• Pathways Physiology, behaviour, cognition
• ?

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• Simultaneous and independent conditions.
• One disorder may prompt the emergence of the
  other, or the two disorders may exist
  independently.
• Example
• History of Depression (inc. family)
• History of Alcoholism (inc. family)
• Interaction pathways as above

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Clues to Primary Problem(not always clear)

• Began before serious secondary problem
• Persists during remission periods of secondary
  problem
• Severity of symptoms in relation to moderate
  levels of secondary problem
• Chronic, acute, uniqueness of symptoms
• Family history

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• Approaches
• Person-Centred
• Necessary but not sufficient
• Doesnt invalidate diagnostic categories
• Case Formulation, including Common
  Factors/Themes
• Common Mood Issues
• Common Motivational Issues
• Common Cognitive Behavioural Issues

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Alcohol Dependence DepressionThemes of
Mood/Reward, Motivation, Cognition, Behaviour
Issue Depression Alcoholism
Mood Low Low mood shifts
Expectation of Reward Low High
Experience of Reward Low Decreasing
Motivation for change Low Ambivalent
Self-belief Low Low
Negativity re future High High
Social withdrawal High Progressive
Self-care Low Low
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Sciacca etc Motivational Interviewing
Cogntive Behavioural Therapy

• www.dualdiagnosis.ie
• http//users.erols.com/ksciacca
• http//integrativecbt.blogspot.com

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Cycle of Change
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CBT Symptom Cycle
Thoughts Emotions Behaviour Physiology
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• TYPES OF DISTORTED THINKING
• 1. All-or-nothing thinking You look at things in
  absolute, black-and-white categories.
• 2. Overgeneralization You view a negative event
  as a never-ending pattern of defeat.
• 3. Mental filter You dwell on the negatives and
  ignore the positives.
• 4. Discounting the positives You insist that
  your accomplishments or positive qualities "don't
  count.
• 5. Jumping to conclusions (A) Mind reading you
  assume that people are reacting negatively to you
  when there is no definite evidence for this (B)
  Fortune-telling you arbitrarily predict that
  things will turn out badly.
• 6. Magnification or minimization You blow things
  up way out of proportion, or you shrink their
  importance inappropriately.
• 7. Emotional reasoning You reason from how you
  feel "I feel like an idiot, so I really must be
  one." Or "I don't feel like doing this, so I'll
  put it off.
• 8. Should statements You criticize yourself or
  other people with "shoulds" etc.