Co-Occurring Disorders: Where Does One End and Another Begin?

Co-Occurring Disorders: Where Does One End and Another Begin? David Mays, MD, PhD dvmays@wisc.edu

Diagnoses From Mendota Mental Health Institute Records • business perplexities • worrying and flow of blood to the brain • became insane in early life from severe study • became insane a few days after his marriage - it is said because of the improper conduct of his wife • bilious fever • unrequited love affair, aggravated blow on the head • worms • softening of the brain • study and novel reading (age 11) • hysteria, neurasthenia, alcoholic psychosis, lunacy

A Brief History of the Diagnostic and Statistical Manual • DSM-I was introduced in 1952, an evolution of a system developed by military psychiatrists. It was issued in conjunction with ICD (International Classification of Disease). Both were medical models of disease. The American Psychiatric Association held the franchise. No one else wanted it. • There were six diseases.

DSM II • DSM-II was introduced in 1968. Neither DSM-I or DSM-II had much impact on mental health practice.

On Being Sane in Insane Places • In February 1969, David Rosenhan (a psychology professor) went to a psychiatric hospital in Pennsylvania, complaining that he heard the words “empty”, “thud”, and “hollow.” He had no other symptoms. He was immediately admitted to this hospital and diagnosed with schizophrenia. Over the next 3 years, seven of his friends and students repeated the same exercise in 11 other hospitals. They were medicated and held in hospitals between 8-52 days. The resulting book claimed that psychiatrists had no valid way to diagnose mental illness.

Follow-Up • A research and teaching hospital challenged Rosenhan to repeat his experiment. Psychiatric staff were warned that at least one pseudo-patient might attempt admission. 83 out of 193 patients (43%) were believed by at least one staff member to be an actor. In fact, Rosenhan sent no actors.

DSM-III • DSM-III, in 1980, introduced the use of “criteria sets,” and operationalized diagnosis. The DSM became a guideline for insurance coverage. • DSM-III-R (1987) and DSM-IV (1994) and DSM-IV-TR (2000) continued this tradition, emphasizing empirical evidence to justify diagnosis. The primary focus has been on reliability.

Problems with Addressed in DSM-5 • 1) Problems with frequent comorbidities: anxiety/depression, antisocial/ADHD/substance abuse, personality disorders • 2) Discrete categories vs. spectrum disorders • 3) Increased use of the NOS category (26% of adults, 21% of children) There are no criteria for an NOS category.

Dr. Thomas Insel, MDDirector, NIMH • Because the goal of DSM-5 is reliability, not validity, we are not getting anywhere in deepening our understanding of the causes of mental disease.

Current Thinking About Mental Illness Points to Continuums, Rather Than a Single Illness • Substance Use • ADHD • Bipolar Disorder • PTSD • Gender Dysphoria • Personality Disorders

The (Several) Bottom Lines • The distinction between what is an illness and what is normal variation is not always clear and frequently changes over time and by culture (obesity, changes of aging, cholesterol, blood pressure, etc.) • DSM criteria are a good place to start in arriving at a diagnosis, but examining only these symptoms will give only a partial view of psychopathology, which is diverse and individual. • Most importantly, diagnostic categories are the constructs of people who want discrete, definable categories. They do not represent “the way things are.” For those of us who try to work in the actual world, we end up trying to force people into an ill-fitting frame.

Common Confusing Clusters • Borderline Personality/Bipolar Disorder/Mood Swings • Trauma Disorders/Behavior Disorders/Mood Disorders/ADHD • Substance Use/Depressive Disorder/Anxiety Disorders/Bipolar Disorder/ Trauma Disorders • Criminal Behavior/ADHD/Bipolar Disorder/Substance Use • Paranoid Schizophrenia/Paranoid Personality/Delusional Disorder • Obsessive Compulsive Disorder/Obsessive Personality/Delusional Disorder • Avoidant Personality/Social Anxiety Disorder • Bipolar Disorder/Intermittent Explosive Disorder/Disruptive Mood Dysregulation Disorder/Reactive Attachment Disorder • Bereavement/Depressive Disorder/Adjustment Disorder

Common Confusing Clusters • Borderline Personality/Bipolar Disorder/Mood Swings • Trauma Disorders/Behavior Disorders/Mood Disorders/ADHD • Substance Use/Depressive Disorder/Anxiety Disorders/Bipolar Disorder/ Trauma • Criminal Behavior/ADHD/Bipolar Disorder/Substance Use • Paranoid Schizophrenia/Paranoid Personality/Delusional Disorder • Obsessive Compulsive Disorder/Obsessive Personality/Delusional Disorder • Avoidant Personality/Social Anxiety Disorder • Bipolar Disorder/Intermittent Explosive Disorder/Disruptive Mood Dysregulation Disorder/Reactive Attachment Disorder • Bereavement/Depressive Disorder/Adjustment Disorder

DSM-IV Substance Use Disorders • Substance Abuse: 1 or more of the following • Failure to fulfill role obligations • Physically hazardous • Legal problems • Recurrent social or interpersonal problems • Substance Dependence: 3 or more of the following • Tolerance • Withdrawal • More use than intended • Unsuccessful efforts to cut down • Much time spent trying to obtain substance • Social, occupational, or recreational activities given up • Continued use despite physical or mental health problems • Specifiers: with or without physiologic dependence

DSM-5 Alcohol Use Disorder • Maladaptive pattern of use leading to impairment and/or distress manifested by 2 or more: • Recurrent use resulting in failure to fulfill role • Physically hazardous (legal issues dropped) • Continued use despite consequences • Tolerance • Withdrawal • Increasing use • Persistent desire to cut down use • Great deal of time spent getting the substance, or to recover from effects • Activities are given up • Craving

Substance Related and Addictive Disorders Specifics • DSM-5 combines abuse and dependence into a single disorder graded by severity. The disorder requires 2 criteria, with 2-3 mild, 4-5 moderate, and 6+ criteria indicating severe. Specifiers for physiologic dependence and course remain. • The task force argues that reliability and validity of the “abuse” diagnosis is poor, the criteria distinguishing abuse and dependence arbitrary, assumptions regarding abuse simply being a prodrome to dependence are incorrect, etc. • See Hasin et al. Am J Psych, Aug 2013.

Addiction in a Nutshell • Addiction is when individuals continue compulsive behavior despite harming themselves. • It involves dysfunction of 3 systems: • The reward/anti-reward system (dopamine, midbrain) • The prefrontal cortex (executive functions, inhibition) • The amygdala (learning and memory) • Clinical correlates: dysphoria, vulnerability to stress, sensitivity to drug-related cues

Dopamine! • Sex (reproduction) • Food (survival) • Warmth, security, shelter, and safety • Alcohol, other drugs of abuse, certain behaviors (gambling, internet use, sexual behavior…)

Preoccupation/Anticipation • In response to any reward, the brain releases dopamine. But with repeated exposure to the reward, the brain responds with dopamine to the stimuli that predict the reward. This is the brain’s way of making sure we act to get the desired behavior. So we are excited by a sexy appearance, or salivate when we smell food cooking. This is called “motivational salience.”

Motivational Salience • People who are addicted have been conditioned not just to taking the drug, but also to the place where they get the drugs, the dealer who sells drugs to them, the friends who are there, the emotional states that precede getting high, etc.

Addiction Changes the Brain • Dopamine pathways are not limited to reward and motivation, but are fundamental in the prefrontal cortex which regulates self-control, working memory, decision-making, and judgment. • The result is the disruption of our ability to make judgments based on changing circumstances, to seek out what is good for us and what is bad for us, and our resulting reaction of shame for our hopelessness and helplessness in trying to control ourselves.

Addictions and Mental Disorders have Multiple Neurotransmitter Links • Decreased central serotonin • Dopaminergic mesolimbic pathway linking ventral tegmentum to nucleus accumbens or ventral striatum • The endogenous opioid system modulating dopamine in the mesolimbic pathway • Cortisol changes • Glutamate involvement in compulsive behavior • Etc…

Video • Video clip from “the Secret Life of the Brain”, PBS DVD, 2002. • www.pbs.org

Substance Use Disorders

Mental Illness in Substance Abusers

Co-occurring Disorders • Epidemiologic studies show that psychiatric disorders increase the risk of substance abuse, and substance abuse increases the risk of psychiatric disorder. Individuals with multiple dependencies experience the highest rate of psychiatric problems. • The reason for the high degree of comorbidity is not known, but certain biochemical commonalities have been observed. The co-occurrence is not coincidental.

Co-occurring Disorders • The inter-relationship is complex: • Both may co-occur • Substances may cause or exacerbate a mental illness • The psychiatric condition may cause or increase the substance abuse • Both may be caused by something else • Substance use and withdrawal may look like a psychiatric disorder • Drug and alcohol use may mask a psychiatric disorder

Compromised Psychosocial Functioning in Co-Occurring Disorders • Pronounced difficulties in employment, education, family, and social relationships (e.g., social isolation) • Serious medical problems • Reduced ability to refrain from substance use • Premature termination from treatment • Rapid progression from initial substance use to substance use disorder • Frequent hospitalization for mental disorders • Housing instability or homelessness

Compromised Psychosocial Functioning • Poor prognosis for completion of treatment • Temporal instability in severity of symptoms related to mental and substance use disorders • Noncompliance with medication and treatment interventions • High rates of depression and suicide • Poor level of engagement and participation • in treatment • Criminal recidivism

People With Co-occurring Conditions • These are the most challenging patients to treat. We must track two conditions in patients who are in denial and are not inclined to follow our recommendations. These patients have poorer outcomes than patients with either disorder alone.

Doing an Assessment(CarlatAddiction Treatment) • 1) Assessment begins immediately, not waiting until the client is abstinent. An integrated longitudinal assessment will help clarify the course of both the mental illness and the substance use disorder, illustrate how they intersect and lead to better treatment decisions. • 2) In COD’s, diagnoses are established by history, not by symptoms alone. You need a history of alcohol use over time. The same is true with the mental illness.

Doing the Assessment • 3) If the patient has a long standing history of mental illness, they will still have a mental illness, even though it looks like the substance abuse is causing all the problems. • 4) Don’t divide the interview into two separate parts. Ask when they were last doing well, what happened tell me what you were doing when you did well, where you were living? What kind of treatment were you getting? How were you staying sober? How did things start to unravel?

Self-Medication • The assessment should consider whether engaging in substance use was motivated by attempts to alleviate symptoms of mental disorders (e.g., agitation, anxiety, depression, sleep disturbance). But everyone who abuses substances will claim that they are only doing it because of a mental disorder (depression, anxiety, PTSD…)

Sequential Treatment of COD’s • Sequential treatment involves treating one type of disorder at a time, with the underlying assumption that either the mental health or substance use disorder is “primary” and must be treated first. • However, since this model does not address the interactive nature of CODs, treating each type of disorder sequentially does not leadto positive long-term outcomes

Parallel/Concurrent Treatment • Another approach involves parallel or concurrent treatment of both types of disorders, allowing offenders to participate in treatment for these disorders simultaneously, but with treatment services typically provided by different agencies. This approach has also led to poor outcomes, does not deal with the intertwined nature of CODs, and can provide confusing or even conflicting messages about recovery and interventions that are needed (e.g., use of medications).

Integrated Treatment • Treatment planning, provision of clinical services, and community supervision strategies should consider the interdependent nature of the disorders. This approach does not necessarily entail providing concurrent services for the disorders in equal intensity, but instead prioritizes the sequence of services according to the presence of acute crises (e.g., suicidal behavior, intoxication) and areas of functional impairment (e.g., cognitive impairment) that affect treatment participation.

Principles of COD Treatment • Some patients will have worse substance abuse, some worse mental illness. • Patience (4 years for 50% to achieve abstinence) and flexibility is required - wet, damp or dry • Medication for the mental illness does not depend on the presence of substance abuse, except to avoid benzodiazepines (tranquilizers) and stimulants. Clients probably benefit from mental health treatment even when they are actively abusing substances.

The Stages of Change Model is Useful • Precontemplation, contemplation, preparation, action, maintenance. Theses stages pretty much describe the process that everyone goes through to make improvement in their lives. • Use the stages of change approach to measure treatment progress and manage your expectations. • Stages of change are problem specific, not person specific. Each person may have many issues and be in different stages of change for each. • Interventions and outcomes have to be stage matched.

Specific Medication Issues • Abstinence is highly desirable before treatment, but not necessary. • Avoid benzodiazepines (tranquilizers) and stimulants. • Beware of overdose in clients with poor judgment or suicidal behavior. • Keep track of prescriptions. • Psychotic disorders: • First generation antipsychotics may worsen substance abuse. Second generation may benefit, especially clozapine.

Specific Medication Issues • Affective disorders • Selective serotonin reuptake inhibitors (SSRI’s) are better than tricyclic antidepressants when there is alcohol abuse. • Anxiety disorders • Avoid benzodiazepines. Try instead SSRI’s, serotonin norepinephrine reuptake inhibitors (SNRI’s), clonidine, second generation antipsychotics. Gabapentin has abuse potential in combination with opioids and is unsafe. • ADHD • Stimulants only after sobriety is established • Can also try bupropion, clonidine, atomoxetine

What Do Clients Say Helps Them the Most? • Stable housing • “Positive” social support • Relying on a higher power • Participating in meaningful activity • Changing how they think about their lives • Attention to eating well, sleeping well, and looking good

Anxiety and Substance Abuse • 18% of substance abusers suffer from an independent anxiety disorder. 70% of alcoholics have anxiety problems, mostly caused by the alcoholism. 15% of anxiety disorder clients have substance abuse problems. The relationship is bidirectional and complex. • Alcohol relieves anxiety in the short term, but chronic drinking makes agoraphobia and social phobia worse.

Anxiety and Substance Abuse • It is difficult to detect substance dependence in the presence of an anxiety disorder. • 98% will report anxiety while drinking/withdrawing, but only 4% after 3 months of abstinence. • Anxiety can be precipitated by caffeine, diet pills, androgenic steroids, etc. Clients with anxiety disorders usually stop the use of marijuana and hallucinogens, but increase the abuse of alcohol and benzodiazepines.

Rules for Pharmacotherapy • It is important to keep control over dosage schedules, amounts dispensed, and refills. • In general, benzodiazepines should not be used because of their abuse potential. • Medication needs to be stopped when it is not helpful.

Anxiety vs. Substance Use • What is the history? Was anxiety present in the person before the substance use? Most mental illnesses have their beginnings in childhood. • What is the timeline of use? How does the use affect the person? When do they feel the anxiety? How long have they been abstinent? How did they feel then? • Is the person willing to work toward abstinence and try non-pharmacological approaches to the anxiety (CBT, meditation, exercise, etc.)

Depression and Substance Abuse • Among those with a history of depression, 40.3% have alcohol abuse, 17.2% have drug abuse, and 30% have nicotine abuse. • Among those with alcohol abuse disorders, 32.75% have major depression, drug abusers, 44.26%. • Individuals with substance abuse often present with complaints of anxiety, sleep disturbance and depression. People with late stage alcoholism feel worthless and helpless. • Treating depression decreases relapse.

Depression vs. Substance Use • Look for evidence of depression before the substance abuse began. • Depression tends to be a later outcome of substance use, unlike anxiety, although self-esteem problems and shame can appear quite early. Look for the vegetative symptoms that go with depression (poor appetite, sleep, poor concentration, lack of pleasure or motivation…)

Bipolar Disorder and Substance Abuse • Bipolar disorder is the affective disorder most commonly associated with substance abuse. 23.6% have an alcohol disorder, 12.9% have a drug abuse disorder, 37% have nicotine dependence. • Bipolar disorder clients are unreliable in their reports of substance use or their psychiatric symptoms. You must get collateral information. • Treatment of one does not resolve the other, but controlled bipolar disease usually leads to diminished substance abuse.

Complications of Substance Abuse and Bipolar Disorder • Stimulants may precipitate a manic phase • Poor response to lithium • Higher mortality from suicide • More mixed mania and rapid cycling • More episodes • Poorer treatment adherence • Slower remission • Sub-optimal response to treatment

Bipolar Disorder vs. Substance Abuse • Usually, there is clear evidence of the bipolar disorder preceding substance use. The criteria require a manic episode that lasts at least a week (or results in hospitalization.) Most of the time a manic episode will last for several weeks to several months.) • Bingeing on amphetamines or cocaine will cause a person to appear manic. But the manic behavior will disappear immediately at detox. • A complication is that people who are manic will preferentially choose amphetamines or cocaine as their drug of choice. (An argument against the self-medication hypothesis.)

Co-Occurring Disorders: Where Does One End and Another Begin?