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1、Addicted, Crazy or Both? Now What? Dual Diagnosis in the CD Patient,Mark Menestrina, MD, FASAM Brighton Hospital / SEMCA mmenestrinabrightonhospital.org Michigan Judges MI 8/2011,Part 1 (the “teaser”),Addiction Review Classification of Mental Disorders Review of Common Disorders Association of Menta
2、l Health Disorders with SUDs,Part 2,Review of Selected Classes of Psychiatric Medications Pharmacology for Recovery Safe Prescribing for Individuals with SUDs,Addiction Review,WE LIVE IN A MAGICAL THINKING MEDICATION SEEKING SOCIETY,USA is 4.7% of the World Population But we consume almost 50% of th
3、e Worlds Drugs and most of the Worlds Pain Medication Media / TV / Radio flood us with messages We are taught not to tolerate any discomfort without taking something to feel better,ADDICTION IS A BRAIN CHEMISTRY DISEASE,Involves the Meso-Limbic System (Primitive) Neurotransmitter Mediated (Not Consc
4、ious) Denial is a Hallmark Feature Emotional, Physical, Psychological Chronic, Progressive, potentially Fatal Affects Family, Community, Society and Schools 10% are susceptible to AddictionTreatable Disease Different than Abuse, anyone can Abuse Drugs or Alcohol.Preventable Behavior,ITS NOT REALLY A
5、 DISEASEIS IT?,1956 AMA designates Alcoholism as a disease, Drug Addiction as a disease followed “But you have a choice” Like depression 30 years ago, or oncology 40 years ago Compare to other Chronic Diseases When we do treat Addiction, we do so Acutely, and wonder why we have poor results,12,Can y
6、ou find the (alleged) future alcoholic?,LACK OF WILLPOWER?,13,IF ADDICTION / CHEMICAL DEPENDENCE IS TRULY A DISEASE.WHY DONT WE TREAT IT AS SUCH?,Leading Causes of Death Data for the U.S. 2007,Age 25-44 Injury Cancer Heart Disease Suicide Homicide HIV Liver Disease Stroke Diabetes,Age 15-24 Injury H
7、omicide Suicide Cancer Heart Disease Congenital Stroke Diabetes,Google: Alcoholism + Humor,The face,of addiction,.and the faces,of recovery,ADDICTION vs. ABUSE,ALCOHOLISM, DRUG ADDICTION, CHEMICAL DEPENDENCE A TREATABLE DISEASE,DRUG ABUSE, ALCOHOL ABUSE A PREVENTABLE BEHAVIOR,THE NEW GATEWAY FOR MAN
8、Y YOUNG PEOPLE,ADDICTION TREATMENT MADE EASY. “A” to “B”,NEGATIVE Consequences: The job, liver, judge, wife, boss, friend get the individuals attention!,POSITIVE Reinforcement: The individual actually begins to like and enjoy “recovery”,While this process is achievable, it is not likely to all make
9、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 DUI CONVICTION.,Co-Occurring Disorders,Psychiatric Illness & Addiction Generalizations,Both are common problems Having one inc
10、reases the risk for having the other Having one complicates the treatment of the other when both are present “Dual Diagnosis” cases are over represented among homeless and incarcerated “Dual Diagnosis” have increased risk of HIV and other serious medical conditions,Classification of Mental Disorders
11、DSM-IV-TR,The official classification system of psychiatric conditions in use in the USA Criteria in DSM are used to facilitate communication among professionals, for research standards, and for 3rd party payor communication DSM- A mental disorder is a disorder with significant behavioral or psychol
12、ogical symptoms associated with present distress, disability or increased risk of suffering death, pain, disability or loss of freedom,THE 5 AXES OF DSM,I. CLINICAL DISORDERS II. PERSONALITY DISORDERS and MENTAL RETARDATION III. GENERAL MEDICAL CONDITIONS IV. PSYCHOSOCIAL AND ENVIORNMENTAL PROBLEMS
13、V. GAF (Global Assessment of Functioning),ASAM DIMENSIONS,I. ACUTE INTOXICATION OR WITHDRAWAL POTENTIAL II. BIOMEDICAL CONDITIONS III. EMOTIONAL, BEHAVIORAL OR COGNITIVE CONDITIONS IV. READINESS TO CHANGE V. RELAPSE POTENTIAL VI. RECOVERY/LIVING ENVIORNMENT,DSM at Work(or not!) Major Depressive Epis
14、ode,Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a genera
15、l medical condition, or mood-incongruent delusions or hallucinations,MDcontinued,(1) 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 i
16、rritable mood. (2) 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),MDcontinued,(3) Significant weight loss when not dieting or weight gain (e.g., a change of more th
17、an 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. (4) Insomnia or hypersomnia nearly every day (5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjecti
18、ve feelings of restlessness or being slowed down),MDcontinued,(6) Fatigue or loss of energy nearly every day (7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) Diminished ability to thi
19、nk or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others,MDcontinued,(9) 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. The
20、 symptoms do not meet criteria for a Mixed Episode (see p. 171) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.,MDcontinued,The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of
21、abuse, a medication) or a general medical condition (e.g., hypothyroidism) The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with wort
22、hlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.,MDdiagnosis in the real world,Depressed mood plus. S sleep disturbance I loss of interest or pleasure (anhedonia) G feelings of guilt or worthlessness E low energy C poor concentration or memory A appetite disturbance P ps
23、ychomotor agitation or retardation S suicidal ideation,REMEMBER THAT DSM CRITERIA ARE HELPFUL GUIDELINESBUT WE ALL HAVE A LITTLE (OR A LOT) IN EACH OF US!,REVIEW OF COMMON DISORDERS,SCHIZOPHRENIA AFFECTIVE DISORDERS ANXIETY DISORDERS (including PTSD) PERSONALITY DISORDERS ATTENTION DEFICIT HYPERACTI
24、VITY EATING DISORDERS SUBSTANCE RELATED DISORDERS,SCHIZOPHRENIA,Complex illness, characterized by hallucinations, delusions, behavioral disturbances, disrupted social functioning, disorganized speech and negative symptoms 0.5-1% Prevalence Violent acts no more frequent than the general population Re
25、duced life expectancy, 40% attempt suicide, 10-20% succeed Treatment antipsychotic medications,AFFECTIVE DISORDERS MOOD DISORDERS,DEPRESSION: common, often missed, not hard to diagnose when you look for it, often severe, often recurrent, costly and highly treatable BIPOLAR DISORDERS Depression with
26、episodes of elevated mood BIPOLAR I= with at least one manic episode BIPOLAR II= with hypomanic episodes,Affective Disorders,ANXIETY DISORDERS,GENERALIZED ANXIETY DISORDER SOCIAL PHOBIA SIMPLE PHOBIAS PANIC DISORDER AGORAPHOBIA PTSD,PERSONALITY DISORDERS,ADHD,Inattention, hyperactivity, impulsivity
27、ADHD does associate with higher risk for SUDs, but this may be limited to those with coexisting conduct or bipolar disorder Treating ADHD with stimulants actually appears to be associated with a decreased risk of developing a subsequent SUD,EATING DISORDERS,ANOREXIA: often severely restrict caloric
28、intake or excessively exercise, are underweight BULEMIA: often alternate eating with starvation or purging, are usually normal weight Both groups may abuse appetite suppressants, diuretics or laxatives BULEMICS appear to be at risk for SUDs One study found ANOREXICS to be at lower risk for SUDs,SUBS
29、TANCE INDUCED DISORDERS,These disorders mimic other psychiatric disorders, but they are in fact caused, directly or indirectly, by use of substances This is a tremendous source of misdiagnosis, and results in ineffective treatment of the substance disorder We live in a society where it is more socia
30、lly acceptable to be mentally ill than chemically dependent,Diagnoses Associated with Class of SubstancesDSM-IV-TR,Substance Induced Mental Disorders,Organic Brain Syndromes SI Delirium SI Persisting Dementia SI Amnestic Disorder Mimic Axis I Disorders SI Psychotic Disorder SI Mood Disorder SI Anxie
31、ty Disorder,Hallucinogen Persisting Perceptual Disorder SI Sexual Dysfunction SI Sleep Disorder,ASSOCIATION OF MENTAL DISORDERS WITH SUDs SUDs include ADDICTION: a treatable disease ABUSE: a preventable behavior,2003 National Survey of Drug Use and Health (NSDUH),21.3% of Adults with Serious Mental
32、Illness (SMI) had a Substance Use Disorder (SUD) 7.9% of Adults without SMI had a SUD,Nicotine and Mental Illness Grant, B.F. et al, 2004,Serious Mental Illness and Its Co-Occurrence with Substance Use Disorders, 2002,Epstein, Barker, Vorburger and Murtha, 2004 SAMHSA.GOV,17.5 million Adults with SM
33、I (Serious Mental Illness) 8.3% of population,18-25yo 13.2% 26-49yo 9.5% 50yo 4.9% Female 10.5% Male 6.0% 1 race 13.6% Nat Am 12.5%,28.9% used illicit drug/yr Illicit drug/yr 17.1% No drug/yr 6.9% SMI did not vary by past year alcohol use Heavy” alcohol/mo 11.1% vs. 8.1%,Co-Occurrence of SMI & SUD,3
34、3.2 million SMI or SUD 13.4 million (40.4%) SMI 15.5 million (47.4%) SUD 4.0 million (12.2%) SMI + SUD Both Disorders: 23.2% of SMI 20.4% of SUD,Rates of SMI.,Lifetime SUD Among Persons with Mental Disorders.Regier et al, 1990,Why the Association?,Common Risk Factors & Etiologies, genetic or environ
35、mental Addiction might lead to Mental Illness Psychiatric Illness might lead to Addictionthe “Self-Treating Hypothesis” Self-Limiting Acute Effects of a Substance (or withdrawal from it) may be mistaken for a psychiatric illness,Affective DisordersAssociation with SUD Regier et.al. 1990,Summary Poin
36、ts,Co-Occurring Disorders are Common May be difficult to differentiate from Substance Induced Disorders Consider “Watchful Waiting” in less definite cases when degree of impairment is not as severe Treatment is often Challenging Both Disorders need to be addressed when both are truly present May be “Road Blocked” by Insurance/Funding Sources,“NEVER DOUBT THAT A SMALL GROUP OF DEDICATED CITIZENS CAN CHANGE THE WORLDINDEED IT IS THE ONLY THING THAT EVER HAS” Margaret Meade,