Comorbidity of Substance Use Disorders and Psychiatric ... · 1/25/2011 · Comorbidity of...
Transcript of Comorbidity of Substance Use Disorders and Psychiatric ... · 1/25/2011 · Comorbidity of...
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HIV NEUROBEHAVIORAL RESEARCH PROGRAMS | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Comorbidity of Substance UseDisorders and
Psychiatric Conditions-2
J. H. Atkinson, M.D.Professor of Psychiatry
HIV Neurobehavioral Research ProgramsUniversity of California, San Diego
KETHEA, Athens, January 25, 2011Slides courtesy of Marc A. Schuckit, M.D.
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DIAGNOSIS IS THE KEY TO:
PrognosisPrognosis
TreatmentTreatment
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WHEN 2+ DISORDERS ARE OBSERVED:
Which one(s) should be treated?Which one(s) should be treated?
What is best therapy?What is best therapy?
Will disorders and/or treatmentsinteract?
Will disorders and/or treatmentsinteract?
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COMORBIDITY IS COMMON IN SUD
BUT
2/3 have 2nd diagnosis2/3 have 2nd diagnosis
Most are ASPD and other SUDMost are ASPD and other SUD
Many others are organicMany others are organic
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SUBSTANCE-INDUCED DISORDER
Prominent symptoms Evidence HX/PE/LAB linking to intense intox. or
withdrawal within 4 wks. Not better accounted for
» Preceded drug» Last >1 month after drug» Type/amount drug not match condition
Significant impairment
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RATIONALE
Drugs can cause psychiatric symptomsDrugs can cause psychiatric symptoms
These last days to weeksThese last days to weeks
They clear spontaneouslyThey clear spontaneously
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DRUG INDUCED STATES
Depression Anxiety Psychosis
Which one(s) should be treated?Which one(s) should be treated?
What is best therapy?What is best therapy?
Will disorders and/or treatmentsinteract?
Will disorders and/or treatmentsinteract?
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CLASSES OF DRUGS MOST LIKELY TOPRODUCE PSYCHOPATHOLOGY
CNS Depressants» Alcohol» Hypnotics» Anti-Anxiety Drugs
CNS Stimulants» Amphetamines» Cocaine» Methylphenidate» Weight Reducers
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STEPS IN ESTABLISHING A SUBSTANCE-INDUCED DISORDER
1) Focus on the full psychiatric syndrome, not onesymptom
2) Be sure the class of drugs can cause thatsyndrome
3) Evaluate Independence using a Timelinea) Determine age of onset of the dependenceb) See if the full psychiatric syndrome was seen before the
dependencec) Determine longer-term abstinence periodsd) See if the full psychiatric syndrome was seen during that
periode) Observe person for ~ 4 weeks of abstinence
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DSM IVMAJOR DEPRESSIVE EPISODE
A. Two Weeks of eitherA. Depressed MoodB. Loss of Interest or Pleasure
B. Five or more of the following symptomspresent during the same two weeks nearlyevery day
A. Weight loss or gain of 5% of body weight in the last month, ordecrease or increase in appetite
B. Insomnia or excessive sleepC. Severe restlessness or being slowed down nearly every day as
observed by othersD. Fatigue or loss of energyE. Feelings of worthlessness or excessive guiltF. Decreased ability to think or concentrate, or indecisivenessG. Thoughts of death or suicidal ideas or plans, or suicide
attempt
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DSM IV™: SUBSTANCE DEPENDENCE
1. Tolerance of substance*2. Withdrawal symptoms*3. Use of large amounts or for longer period than intended4. Inability to, or persistent desire to, cut down or control
use5. A great deal of time spent obtaining, using, or
recovering from use6. Important activities given up or reduced7. Use despite recognition of associated physical and/or
psychological problems
*Dx: “with Physiological Dependence”
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ALCOHOL CAUSES DEPRESSION
Acute Alcohol Challenges Chronic Alcohol Experiments Alcoholics
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DEPRESSION AMONG STIMULANT ANDDEPRESSANT ABUSERS
Syndrome %
Moderate Depression 80
Severe Depression 30-40
2+ Week Depression 30
Independent Depression 5-15
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Hamilton Depression
Score > 20 (percent)
Weeks
40
20
30
10
0
1 2 4 163
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Time Line Example
Major depressive episodes
27 33 33.5X X
Onset of alcoholdependence
6-monthperiod of
abstinence*
Birth40 years
Can monitor with state markers, toxicologyscreens, other informants
*
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TREATMENT
1. Address Symptoms Acutely2. Educate and Reassure3. Evaluate Timeline4. Reserve Antidepressants for
MDD and Lithium, etc. for Bipolar Disorder
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ACCESS TO TREATMENT
Philosophy Integrate Begin New Use All Resources
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MANIC EPISODE
A. Abnormal + Persistent Elevated or IrritableMood 1+ Week
B. 3+ of : Grandiose, SleepNeed, Talkative, Flight Ideas,
Distractability, Activity, Pleasure Seek
C. Impaired Functioning
Dr Atkinson – I couldn’t figure out how this was supposed to layout…
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PSYCHOSIS
Hallucinations and/or Delusions In a Clear Sensorium Without Insight
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STIMULANT PSYCHOSIS
Can Occur in Anyone Symptoms Can Include:
» Paranoia» Hallucinations» Emotional Changes» Motor Changes
Disappears with Abstinence
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The Time Line
Birth Present Age
1. Age at which substance problems 1stclustered
2. Ages at which abstinence of 3+ monthsoccurred
3. Ages of other major disorders4. Unless substance and other psychiatric
disorders are clearly separate, assume thatpsychiatric problems will clear.
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NERVOUSNESS VS PATHOLOGICALANXIETY
Rule Out Medical Problems Primary Anxiety Disorders
» Panic Disorders» Agoraphobia» Social Phobia» Obsessive Compulsive Disorder
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ANXIETY DISORDERS
Generalized Anxiety Disorder Panic Disorder Phobias Posttraumatic Stress Disorder Obsessive-Compulsive Disorder
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ANXIETY
Rule Out Stimulant Intoxication Depressant Withdrawal
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171 PRIMARY ALCOHOLICS
Syndrome %
Withdrawal palpitations and/orshortness of breath 80
Panic while drinking 4
Panic while sober 2
Generalized anxiety whilesober 4
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_X Spielburger State Anxiety
40
0
30
1 2 3 4 16Weeks
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FOR ANY SEVERE IMPAIRMENT
Treat all emergencies Educate Reassure Behavioral Rx Cognitive Rx
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DRUGS OF ABUSE
Exacerbate Prior Psychiatric Disorders byIncreasing:» Mood Swings» Anxiety» Paranoia» Hallucinations» Confusion
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OTHER TREATMENT ISSUES
Housing Cognitive/Behavioral Specific Self-Help Groups Staffing Training Staff Therapeutic Communities
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Diagnostic ProcessCase Examples
Expected effects of intoxicationand withdrawal Primary psychiatric disorder Substance induced disorders
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Expected Effects of Intoxication andWithdrawal-1
Alcohol, Stimulant and Opioid Intoxication
» Elevated Mood» Depressed Mood» Loss of interest» Insomnia» Restlessness» Poor Concentration
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Expected Effects of Intoxication andWithdrawal-2
Alcohol, Stimulant, Nicotine and Opioid Withdrawal
» Anxiety» Irritability» Restlessness» Depressed Mood» Sleep Problems» Appetite Changes
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CannabisWithdrawal Symptoms(Budney et al ., 1999)
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Primary depression before andafter substance abuse
GEORGE AND JOAN
Case Examples
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George - 1
Primary Depression Beginning Before Substance
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George - 2
Primary Depression Beginning Before Substance
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Joan - 1
Primary Depression Continuing After Substance
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Joan - 2
Primary Depression Continuing After Substance
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Substance-Induced majordepressive syndrome
AL
Case Examples
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Al - 1
Substance-induced major depressive syndrome
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Al - 2
Substance-induced major depressive syndrome
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Al - 3
Substance-induced major depressive syndrome
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Al - 4
Substance-induced major depressive syndrome
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Expected effects of alcohol:Insomnia
RENEE
Case Examples
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Renee - 1
Expected effects of alcohol: Insomnia
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Renee - 2
Expected effects of alcohol: Insomnia
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Renee - 3
Expected effects of alcohol: Insomnia
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Renee - 4
Expected effects of alcohol: Insomnia
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Expected effects of alcohol:Symptoms
BOB
Case Examples
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Bob - 1
Expected effects of alcohol: Symptoms
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Bob - 2
Expected effects of alcohol: Symptoms
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Bob - 3
Expected effects of alcohol: Symptoms
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Bob - 4
Expected effects of alcohol: Symptoms
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Substance-Induced majordepressive syndrome
DOUG
Case Examples
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Doug - 1
Substance-induced depressive symptom: concentration
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Doug - 2
Substance-induced depressive symptom: concentration
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Doug - 3
Substance-induced depressive symptom: concentration
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Doug - 4
Substance-induced depressive symptom: concentration
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Substance-Induced majordepressive syndrome
SUSAN
Case Examples
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Susan - 1
Substance-induced major depressive syndrome
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Susan - 2
Substance-induced major depressive syndrome
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Susan - 3
Substance-induced major depressive syndrome
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Susan - 4
Substance-induced major depressive syndrome
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QUESTIONS?
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Thank you