Co-OCCURING DISORDERS IN ADDICTION

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1 Co-OCCURING DISORDERS IN ADDICTION Part 2: DSM AND BEYOND Diagnosis of CODs A Workshop for Alameda County SUD Treatment Providers February 26, 2016 Rob Lee MD

2 The DSM: Diagnostic and Statistical Manual of Mental Disorders Published since 1952 by the American Psychiatric Association, revised every ~15 years Current edition DSM-5 published May 2013 Some are disappointed that there is relatively little advance from DSM-4 of 1994 Alameda County has decided to continue to officially use DSM-4-TR instead of DSM-5, but there are advantages to DSM-5

3 DSM-5 (2013) versus DSM-4 (1994) Diagnosis Names and Criteria are modestly reorganized and simplified Diagnosis Codes are given in both ICD-10 (new) and ICD-9 (old) formats The Axis system is abandoned, and Personality Disorders are given equal status to other MHDs Trauma/Stress Disorders are a separate Major Group, including Adjustment Disorders OCDs are a separate Major Group SUD diagnosis is significantly improved:

4 Substance-Related and Addictive Disorders in DSM-5 DSM-5 drops the ambiguous terms Abuse and Dependence, instead uses Substance Use Disorder (SUD) as a single comprehensive term for addiction Diagnosis Criteria are expanded to 11: Craving + 8 aspects of Compulsion and/or Poor Judgment+ 2 Physiologic aspects (Tolerance, Dependence/Withdrawal) Mild SUD= 2-3 criteria, Moderate SUD= 4-5 criteria, Severe SUD= 6 or more criteria

5 Problems with the DSM Most DSM diagnoses are spectrum disorders and overlap greatly with other diagnoses and with normal: Issue of Poor Reliability Diagnostic thresholds may be too low for some disorders: Issue of Over-Diagnosis leading to over-treatment DSM diagnoses are influenced by experience with medications, and some see this as Pharmaceutical Bias DSM Criteria make almost no reference to Brain or Genetic Science, and some see this as a glaring Lack of Hard Science Basis. (But such basis is not yet possible, may not be clinically realistic for many years.

6 A Word on Genetics Human Genome was sequenced in 2001, and expectations were high that genetic bases for many MHDs would be discovered Many gene variations have been found, but few clear mechanisms have been revealed Key MHDs (Bipolar, Schizophrenia, Depression) are associated with 100s of genetic variations These genetic variations are pleiotropic (non-specific), associating with multiple MHDs

7 DSM and ICD-10 The ICD-10 (10 th edition of the International Classification of Diseases) has been used since 1994(!) by Europe and most other countries CMS (Medicare & Medicaid) finally mandated USA providers to switch to ICD-10 in October 2015 ICD diagnoses are somewhat different from DSM and codes are very different (alpha-numerics) Will DSM survive?: DSM is a uniquely elaborate and tested clinical system that will dominate psychology for the foreseeable future

8 Co-Occurring Disorders (CODs) Previously called Dual Diagnosis Conditions DEF= Any diagnosable Mental Health Disorder that accompanies a Substance Use Disorder In a typical SUD population 50% have COD, whereas in a non-sud population Mental Health Disorder prevalence is 20% MOST MHDs are frequent CODs. Major Exceptions: Cognitive and Autistic Disorders

9 Basis of Co-Occurrence? Coincidence? Shared Genetic or Brain Problem(s)? Shared Environmental Cause(s)? SUD induces (causes OR activates) MHD? Psychic Pain from MHD leads to SUD? Self Treatment of specific MHD symptoms? Poor Judgment due to MH Disorder?

10 Substance-Induced MHDs in Acute Drug Use(A), in Drug Withdrawal (W), in Chronic Drug Use(C) Perceptual distortions (hallucinations) A,W,C Delirium/Confusion A,W Anxiety/Insomnia/Panic A,W,C Depression W,C Psychosis A,W,C Mania A,W,C Seizures W,C Memory Impairment or Dementia A,W,C

11 Approaching Substance-Induced Disorders Most will resolve within 30 days of abstinence Many can be managed without medication intervention, but intervention is appropriate if the Disorder is severe: Risk of death, violence or physical harm; or persistent/harmful dysfunction Disorders persisting beyond 30 days should be evaluated for medical causes or missed COD Full recovery in abstinence may in some cases (eg, methamphetamine psychosis) take 6-24 mos

12 Psychic Pain Adverse Activation of the Emotional Brain, traditionally called the Limbic System Does dopamine, the neurotransmitter of addiction, counter-act psychic pain? Dysphoria vs Anhedonia Activation of the Nucleus Accumbens, the brain pleasure center directly relieves anhedonia and likely also decreases dysphoria in the amygdala-hippocampus system

13 The Limbic System Emotional-Cognitive Centers of the Brain

14 Brain Reward and Emotional Tone Systems Nucleus Accumbens and Amygdala- Hippocampus

15 The Principal CODs Bipolar Disorders Psychosis/Schizophrenia Depressive Disorders Anxiety Disorders (Panic, OCD, GAD, Phobias) ADHD Trauma Disorders/PTSD Eating Disorders Personality Disorders (ASPD, BPD, STPD) [Chronic Pain]

16 Understanding CODs Heritability and Brain Biological Mechanisms --Discussed in Workshop #1 Diagnostic Criteria, from DSM Prevalence, Generally & in SUD Clients Issues during SUD Treatment Course & Prognosis Medical Treatments (if any) --Discussed in Workshop #3

17 COD: Bipolar Disorders Nutshell DSM Criteria Bipolar I: H/O Mania (even 1 episode is sufficient) not caused by drugs Bipolar II: H/O Hypomania (but not Mania) not caused by drugs, and at least 1 Major Depression Mania=7 days or more of at least 3 symptoms severely: Distracted, Inflated/Irritable mood, Racing thoughts, Talking more, Judgment poor, Overactive, Bed-time (sleeping) decreased Hypomania=4 days or more of at least 3 of the above symptoms but less severely (hospitalization not needed)

18 COD: Bipolar Disorder (BAD) Considerations in SUD Treatment BAD prevalence (Types I & II together) is about 2% of the general population, but BAD increases SUD greatly, and may be 10% or more of an SUD population Alcohol is the DOC, but any substance may be used Substance Use frequently induces Mania or Depression in BAD Fully manic clients need hospitalization: Risk of selfharm or violence Recovery generally, and Compliance/Participation in particular, are often impaired by mood instability or poor judgment (long-lasting cognitive problems)

19 BAD: Treatment and Prognosis Medical treatment is necessary, often resisted Education is critical, sometimes difficult Issue of kindling : Manic episodes may set up further manic episodes Depression often severe: High suicide risk, 15-25% 15-25% of Depression may be unrecognized BAD MEDS: [Lithium], Valproate, Antipsychotics (2 nd Gen) Prognosis can be excellent with compliance, but often the course is poor Possibility of remission is uncertain, and at best requires many consecutive years of stability

20 COD: Psychosis/Schizophrenia Nutshell DSM Criteria Psychosis= Two or more of: Delusions, (Auditory) Hallucinations, Disorganized Speech (and Thought), Disorganized Behavior Schizophrenia= Psychosis persistent for 6 months, socially impairing, and not caused by drugs, mania, or other brain disorder The same criteria persistent <1 month is Brief Psychotic Disorder, or Schizophreniform Disorder if persistent 1-6 months

21 COD: Psychosis/Schizophrenia Considerations in SUD Treatment The majority (70%?) of psychoses in an SUD population are drug-induced, and will resolve if abstinence is stabilized 1% of the general population is schizophrenic, but SUD risk is increased and incidence in an SUD population may be 2-5% Most (90%?) also smoke cigarettes Drugs both cause and activate psychotic disorders Schizophrenics with SUD have an extremely difficult course and require a high amount of assistance

22 Schizophrenia: Course and Prognosis A highly variable disorder, probably with many different genetic causes Impairment of cognition/judgment is very common, perhaps in 90% Medications (antipsychotics, especially) are usually needed for stability and compliance is often incomplete, unpredictable Current meds may not prevent or slow progression Over time (often decades) lasting stability may be achieved, sometimes even off meds, if SUD stops

23 COD: Depression Disorders Nutshell DSM Criteria Major Depression= Depressed mood for at least 2 weeks and five or more of: Sleep disturbance, Appetite disturbance, Motor activity change, Energy loss, Suicidal thinking, Anhedonia, Deprecation of self ( worthless & hopeless ), Concentration impairment Dysthymia (mild Chronic Depression)= Depressed mood most days for 2 years or more and at least two but not five of the above criteria

24 COD: Depression Disorders Considerations in SUD Treatment Primary Major Depression only moderately increases SUD, and Dysthymia increases SUD mildly However, Depression Disorders induced by SUD are extremely common Alcohol, Sedatives, Stimulants, Opioids and Hallucinogens, all induce depression in both chronic use and withdrawal Depressed SUD clients will have increased craving and decreased capacity for recovery Major Depression in SUD has a very high suicide risk

25 Depression Disorders Course and Prognosis Recurrent Major Depression may be self-kindling and can become extremely persistent MANY medical conditions, as well as diet and lifestyle, greatly impact onset and recovery from depression Medications are definitely indicated, and work, but about 25% of cases are Treatment Resistant some of these will be undiagnosed BAD Type I or II Stable abstinence is needed for depression remission With abstinence, most depression clients can remit but some may need carefully managed long-term meds CBT and other psychotherapies usually help remission

26 COD: Anxiety Disorders that moderately raise SUD Risk Nutshell DSM Criteria Panic Disorder (PD)= Sudden attacks (onset <10 min, last 15-60mins) of overwhelming anxiety with multiple chest/heart/abdominal/neurological symptoms that stop when the panic stops Agoraphobia (fear of public places) usually results from frequent panic attacks Obsessive-Compulsive Disorder (OCD)= Persistent Obsessions and/or Compulsions: Excessive and useless/distressing thinking that cannot be suppressed and/or excessive and useless/distressing activities( rituals ) that cannot be suppressed

27 COD: Anxiety Disorders that only mildly raise SUD Risk Nutshell DSM Criteria Generalized Anxiety (GAD)= Chronic (>6 mos) excessive and troubling worry/anxiety about many various issues, not caused by drugs or medical conditions Social Phobia= Shyness: Excessive anxiety when in public, usually severe/disabling when performing : Speaking, writing, even eating

28 COD: Anxiety Disorders Considerations in SUD Treatment Anxiety Disorders, if recognized, can usually be treated satisfactorily, but if untreated cause mildmoderate risk of SUD (usually alcohol or pills) Anxiety and Panic are frequently induced by drugs: Either in chronic use or withdrawal Anxiety increases drug craving With abstinence most drug-induced anxiety greatly improves or resolves by 1 month Recurrent panics or severe anxiety should be treated

29 Anxiety Disorders Course and Prognosis Serotonin-augmenting medications are mainstays and are usually effective if managed carefully ( start low, go slow ) Benzodiazepines are not safe long-term meds, tho useful for short periods or infrequent PRN use Poor sleep exaggerates anxiety, and insomnia should be recognized and addressed If anxiety pre-dated SUD it may be primary and persist for many years, but generally improves with age if treated appropriately CBT and other psychotherapies are often helpful

30 COD: Attention Deficit Disorder (ADD) Nutshell DSM Criteria ADHD is usually the childhood form This disorder persists in 2.5-to-5% of the adult population, usually as ADD (less hyperactivity) DSM applied to adults= A problem that started before age 12 marked by at least five of: Inattention to details, Inattention at tasks, Impaired listening, Unfinished tasks, Disorganization, Avoidance of tasks, Losing things, Distractability, Forgetfulness/Lateness Adults may also be impulsive, over-talkative, fidgety Criteria are common/vague, and ADD may be overdiagnosed, but True Cases can be very impaired

31 COD: ADD Considerations in SUD Treatment ADD adults frequently misuse alcohol and MJ and may become addicted Antisocial Personality Disorder sometimes co-occurs with ADD and greatly increases the risk for addiction Drugs do not appear to cause or worsen ADD Stimulant ADD medications (methylphenidate, amphetamine) are contraindicated during early stages of SUD Treatment Participation and Recovery can be impaired by inattention and disorganization Recognition of the disorder may help both client and staff

32 ADD: Course and Prognosis Much improvement in ADD symptoms can be achieved through education and behavioral skills More severe ADD often also benefits from medication: Non-addictive options are bupropion and guanfacine, both only moderately effective When stable recovery is achieved, some physicians will re-treat selected clients with long-acting (less addictive) psychostimulants IF these medications were not abused in the past Full remission of ADD after adulthood is considered rare but a full/successful life is possible

33 COD: Trauma Disorders/PTSD Nutshell DSM Criteria PTSD= A complex persistent (>1 mo) reaction to catastrophic trauma (strong threat to life, serious injury, or sexual violence), with 4 symptom clusters: Re-experiencing: flashbacks, nightmares, etc Avoidance: numbing, refusal to discuss or remember Hyperarousal: insomnia, irritability, startle, dysfocus, etc Mood-Cognition: depression, amnesia, distortions, etc Adjustment Disorders are temporary (<6 months) milder emotional reactions to moderate stresstrauma

34 COD: Trauma Disorders/PTSD Considerations in SUD Treatment Adjustment Disorders rarely cause SUD, but occur frequently as consequences of SUD PTSD, a chronic and highly disruptive/painful condition, frequently leads to SUD PTSD is common (~10%) in the general population and extremely common (30%?) in the SUD population Complex (Childhood) PTSD is an important subcategory not yet recognized in the DSM SUD (mainly Alcohol, Sedatives, MJ) usually prevents recovery from PTSD

35 PTSD/Trauma Disorders Course and Prognosis Despair, Depression, Self-harm are possible In ex-military (and others too) PTSD may be complicated by Traumatic Brain Injury (TBI), sometimes unrecognized Effective treatment programs de-toxify and reorganize traumatic memories, prevent re-trauma Medications may be helpful at times for severe symptoms: Insomnia, Depression, Panic Attacks Substantial, sometimes complete, recovery from PTSD is possible if abstinence is stabilized

36 COD: Eating Disorders Nutshell DSM Criteria Anorexia= Refusal to maintain weight above a BMI of 17.5 (85% of normal), with distorted/delusional body image, and loss of menses Bulimia= Frequent (on average 2x/wk) compulsive bingeing on selected foods, followed by compensatory purging (vomiting, laxatives, enemas, diuretics) Binge Eating= Frequent compulsive bingeing but without purging

37 COD: Eating Disorders Considerations in SUD Treatment Eating Disorders (EDs) strongly resemble SUDs, except that the substance is an eating behavior EDs have a high risk of SUD, especially stimulants, but SUDs do not cause EDs Frequently, ED clients may hide their disorder and go unrecognized Recovery is difficult and incomplete if ED persists Anorexia with weight below BMI 17 has starvation health consequences, may need hospitalization

38 Eating Disorders Course and Prognosis Eating Disorders usually begin in youth and, like teenage SUDs, may resolve with maturation and/or treatment Most effective treatments are behavioral & cognitive interventions, with family therapy if possible/appropriate Medications (eg, SSRIs) have some benefit in binge-type EDs, but only a limited case-by-case role in anorexia Unremitting anorexia has an extremely high death rate, both from suicide and medical problems Persistent or severe Eating Disorders should be referred to Specialty clinics or therapists

39 COD: Personality Disorders There are ten Personality Disorders in DSM-5, but mainly three are associated with risk of SUD: Antisocial Personality Disorder (ASPD) Borderline Personality Disorder (BPD) Schizotypal Personality Disorder (STPD) Heritability is high, around 70% in each case Nonetheless, there is some association with trauma: Physical/emotional in ASPD, Sexual/emotional in BPD, Neglect in STPD

40 Antisocial Personality Disorders (ASPD) Nutshell DSM Criteria ASPD= A chronic and consistent pattern, starting before age 15, of disregarding the rights of others, and often also marked by risk-taking and impulsivity 1-2% of general population but as high as 10% among SUD clients Brain studies suggest underactive amygdala, and prefrontal cortex (OMFC and DLFC areas)

41 Borderline Personality Disorder (BPD) Nutshell Criteria BPD= A chronic and persistent pattern, starting before age 25, of unstable mood, self-image and relationships, often accompanied by suicidality, self-harm, and/or rage outbursts 2-4% of the population, but perhaps 4-8% of SUD clients Brain studies suggest overactive amygdala and underactive ACG (area of the prefrontal cortex) Course is variable with definite suicide risk, but many improve greatly in their 40s or 50s

42 Schizotypal Personality Disorder (STPD) Nutshell Criteria STPD= A chronic and consistent pattern starting before age 25 of social discomfort & suspiciousness & isolation, usually accompanied by odd (but not psychotic) ideas /beliefs and perceptions. These persons tend to keep alone and have few if any non-family friends 1-2% of the population and 3-4% of SUD clients Brain changes similar to Schizophrenia but milder

43 COD: Personality Disorders Considerations in SUD Treatment ASPD greatly increases SUD risk (~80% over lifetime) and BPD or STPD moderately increases SUD risk Drugs do not induce personality disorders About 50% of inmates in Criminal Justice meet ASPD criteria ASPD may be non-compliant or manipulative, but if intelligence is good there is possibility of recovery and success BPD if severe will require extensive staff time for management, and some cases may not be appropriate for some SUD Treatment Programs STPD will be difficult to engage, quirky, suspicious

44 Personality Disorders Course and Prognosis Personality Disorders are considered life-long traits that can be ameliorated by persistent effort over the years Medications have a limited role, treating depression or anxiety or psychosis if they arise PDs benefit enormously from consistency and fair/sane rules and boundaries Long-term prognosis depends on intelligence/insight Long-term treatment (usually centered around a psychotherapist) is desirable but acceptance may be low

45 Chronic Pain The COD that is not in the DSM Chronic pain (due to arthritis, back injury, fibromyalgia, migraine, trauma, etc) is an increasingly frequent problem, with major psychological effects, but is not directly addressed in the DSM Since 2001 physicians have been encouraged to treat chronic pain more aggressively, included with opioids An epidemic of pain-pill abuse and addiction has resulted, sometimes leading on to heroin use or use of other street drugs Chronic pain in SUD clients is a complex and difficult issue that we must discuss at another time

46 COD clients in SUD Treatment may stand out in: Needing medications to function or stabilize Needing education about their Disorder in order to cope and make sense of their lives More need for support and patience More craving and SUD instability More stigma, more denial More history of trauma More risk of suicide or (less often) violence Cognitive problems in some cases

47 Approaching CODs in SUD Knowledge gives clinical strength and skill: It is best to become familiar with the DSM criteria, at least in nutshell form, for the major CODs Always ask new clients about past COD diagnoses, and try to verify them as much as possible If you interview clients, use questions and instruments (eg, the ASI) that may point to an unrecognized COD If anxiety or depression or psychosis continues beyond one month of abstinence, consider the possibility of an unrecognized primary COD Establishing a new COD diagnosis should usually be a slow, thoughtful team-based process, with outside consultation in most cases

48 Diagnosis is not a full representation of the person, but may be a window into the patterns of the brain on which he is dependent. If diagnosis is skillful, a new avenue of treatment may be opened. In attempting to turn back the dire illness of addiction, we cannot afford to disregard this possibility.

Psychological Disorders. Schizophrenia Spectrum & Other Psychotic Disorders. Schizophrenia. Neurodevelopmental Disorders 4/12/2018

Psychological Disorders. Schizophrenia Spectrum & Other Psychotic Disorders. Schizophrenia. Neurodevelopmental Disorders 4/12/2018 Psychological s Schizophrenia Spectrum & Other Psychotic s Schizophrenia Spectrum & Other Psychotic s 0Presence of delusions, hallucinations, disorganized thinking/speech, disorganized or abnormal motor