Comorbidity of Substance Use Disorders and Psychiatric Conditions-2

Transcription

1 Comorbidity of Substance Use Disorders and Psychiatric Conditions-2 J. H. Atkinson, M.D. Professor of Psychiatry HIV Neurobehavioral Research Programs University of California, San Diego KETHEA, Athens, January 25, 2011 Slides courtesy of Marc A. Schuckit, M.D. DIAGNOSIS IS THE KEY TO: Prognosis Treatment WHEN 2+ DISORDERS ARE OBSERVED: Which one(s) should be treated? What is best therapy? Will disorders and/or treatments Will disorders and/or treatments interact? 1

2 COMORBIDITY IS COMMON IN SUD 2/3 have 2 nd diagnosis BUT Most are ASPD and other SUD Many others are organic 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 RATIONALE Drugs can cause psychiatric symptoms These last days to weeks They clear spontaneously 2

3 DRUG INDUCED STATES Depression Anxiety Which one(s) should be treated? Psychosis What is best therapy? Will disorders and/or treatments interact? CLASSES OF DRUGS MOST LIKELY TO PRODUCE PSYCHOPATHOLOGY CNS Depressants» Alcohol» Hypnotics» Anti-Anxiety Drugs CNS Stimulants» Amphetamines» Cocaine» Methylphenidate» Weight Reducers STEPS IN ESTABLISHING A SUBSTANCE- INDUCED DISORDER 1) Focus on the full psychiatric syndrome, not one symptom 2) Be sure the class of drugs can cause that syndrome 3) Evaluate Independence using a Timeline a) Determine age of onset of the dependence b) See if the full psychiatric syndrome was seen before the dependence c) Determine longer-term abstinence periods d) See if the full psychiatric syndrome was seen during that period e) Observe person for ~ 4 weeks of abstinence 3

4 DSM IV MAJOR DEPRESSIVE EPISODE A. Two Weeks of either A. Depressed Mood B. Loss of Interest or Pleasure B. Five or more of the following symptoms present during the same two weeks nearly every day A. Weight loss or gain of 5% of body weight in the last month, or decrease or increase in appetite B. Insomnia or excessive sleep C. Severe restlessness or being slowed down nearly every day as observed by others D. Fatigue or loss of energy E. Feelings of worthlessness or excessive guilt F. Decreased ability to think or concentrate, or indecisiveness G. Thoughts of death or suicidal ideas or plans, or suicide attempt DSM IV : SUBSTANCE DEPENDENCE 1. Tolerance of substance* 2. Withdrawal symptoms* 3. Use of large amounts or for longer period than intended 4. Inability to, or persistent desire to, cut down or control use 5. A great deal of time spent obtaining, using, or recovering from use 6. Important activities given up or reduced 7. Use despite recognition of associated physical and/or psychological problems *Dx: with Physiological Dependence ALCOHOL CAUSES DEPRESSION Acute Alcohol Challenges Chronic Alcohol Experiments Alcoholics 4

5 DEPRESSION AMONG STIMULANT AND DEPRESSANT ABUSERS Syndrome % Moderate Depression 80 Severe Depression Week Depression 30 Independent Depression 5-15 Hamilton Depression 40 Score > 20 (percent) Weeks Time Line Example Birth Onset of alcohol dependence X 6-month period of abstinence* X 40 years Major depressive episodes * Can monitor with state markers, toxicology screens, other informants 5

6 TREATMENT 1. Address Symptoms Acutely 2. Educate and Reassure 3. Evaluate Timeline 4. Reserve Antidepressants for MDD and Lithium, etc. for Bipolar Disorder ACCESS TO TREATMENT Philosophy Integrate Begin New Use All Resources MANIC EPISODE Dr Atkinson I couldn t figure out how this was supposed to layout A. Abnormal + Persistent Elevated or Irritable Mood 1+ Week B. 3+ of : Grandiose, Sleep Need, Talkative, Flight Ideas, Distractability, Activity, Pleasure Seek C. Impaired Functioning 6

7 PSYCHOSIS Hallucinations and/or Delusions In a Clear Sensorium Without Insight STIMULANT PSYCHOSIS Can Occur in Anyone Symptoms Can Include:» Paranoia» Hallucinations» Emotional Changes» Motor Changes Disappears with Abstinence The Time Line Birth Present Age 1. Age at which substance problems 1st clustered 2. Ages at which abstinence of 3+ months occurred 3. Ages of other major disorders 4. Unless substance and other psychiatric disorders are clearly separate, assume that psychiatric problems will clear. 7

8 NERVOUSNESS VS PATHOLOGICAL ANXIETY Rule Out Medical Problems Primary Anxiety Disorders» Panic Disorders» Agoraphobia» Social Phobia» Obsessive Compulsive Disorder ANXIETY DISORDERS Generalized Anxiety Disorder Panic Disorder Phobias Posttraumatic Stress Disorder Obsessive-Compulsive Disorder ANXIETY Rule Out Stimulant Intoxication Depressant Withdrawal 8

9 171 PRIMARY ALCOHOLICS Syndrome % Withdrawal palpitations and/or shortness of breath 80 Panic while drinking 4 Panic while sober 2 Generalized anxiety while sober 4 _ X Spielburger State Anxiety Weeks FOR ANY SEVERE IMPAIRMENT Treat all emergencies Educate Reassure Behavioral Rx Cognitive Rx 9

10 DRUGS OF ABUSE Exacerbate Prior Psychiatric Disorders by Increasing:» Mood Swings» Anxiety» Paranoia» Hallucinations» Confusion OTHER TREATMENT ISSUES Housing Cognitive/Behavioral Specific Self-Help Groups Staffing Training Staff Therapeutic Communities Case Examples Diagnostic Process Expected effects of intoxication and withdrawal Primary psychiatric disorder Substance induced disorders 10

11 Expected Effects of Intoxication and Withdrawal-1 Alcohol, Stimulant and Opioid Intoxication» Elevated Mood» Depressed Mood» Loss of interest» Insomnia» Restlessness» Poor Concentration Expected Effects of Intoxication and Withdrawal-2 Alcohol, Stimulant, Nicotine and Opioid Withdrawal» Anxiety» Irritability» Restlessness» Depressed Mood» Sleep Problems» Appetite Changes CannabisWithdrawal Symptoms (Budney et al., 1999) 11

12 Case Examples Primary depression before and after substance abuse GEORGE AND JOAN George - 1 Primary Depression Beginning Before Substance George - 2 Primary Depression Beginning Before Substance 12

13 Joan - 1 Primary Depression Continuing After Substance Joan - 2 Primary Depression Continuing After Substance Case Examples Substance-Induced major depressive syndrome AL 13

14 Al - 1 Substance-induced major depressive syndrome Al - 2 Substance-induced major depressive syndrome Al - 3 Substance-induced major depressive syndrome 14

15 Al - 4 Substance-induced major depressive syndrome Case Examples Expected effects of alcohol: Insomnia RENEE Renee - 1 Expected effects of alcohol: Insomnia 15

16 Renee - 2 Expected effects of alcohol: Insomnia Renee - 3 Expected effects of alcohol: Insomnia Renee - 4 Expected effects of alcohol: Insomnia 16

17 Case Examples Expected effects of alcohol: Symptoms BOB Bob - 1 Expected effects of alcohol: Symptoms Bob - 2 Expected effects of alcohol: Symptoms 17

18 Bob - 3 Expected effects of alcohol: Symptoms Bob - 4 Expected effects of alcohol: Symptoms Case Examples Substance-Induced major depressive syndrome DOUG 18

19 Doug - 1 Substance-induced depressive symptom: concentration Doug - 2 Substance-induced depressive symptom: concentration Doug - 3 Substance-induced depressive symptom: concentration 19

20 Doug - 4 Substance-induced depressive symptom: concentration Case Examples Substance-Induced major depressive syndrome SUSAN Susan - 1 Substance-induced major depressive syndrome 20

21 Susan - 2 Substance-induced major depressive syndrome Susan - 3 Substance-induced major depressive syndrome Susan - 4 Substance-induced major depressive syndrome 21

22 QUESTIONS? Thank you 22