Conduct Disorder - Diagnostic Features

1. Conduct Disorder - Diagnostic Features Repetitive and persistent behaviors in which the basic rights of others, societal norms or rules are violated as evidenced by: Aggression to people and animal • Destruction of property • Deceitfulness or theft • Serious violations of rules - Bullies, threatens or intimidates others - Often initiates physical fights Has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun) JP CounselingHealing for Adults, Youth and Families

2. Mood Disorders • Generic term referencing a collective group of specific diagnosable disorders • Major Depressive Disorder most common - Twice as common in adolescent & adult females than their male counterparts - In adolescence more likely to manifest as irritability than sadness - Later onset than substance abuse • Prominent mood liability and dysregulation • Onset of psychopathology preceded or coincided with SU for other disorders JP CounselingHealing for Adults, Youth and Families

3. Mood Disorders DSM 5 Major Categories • Depressive Disorders • Bipolar Disorders • Other - Substance-Induced Mood Disorders - Premenstrual Dysphoric Disorder JP CounselingHealing for Adults, Youth and Families

4. Anxiety Disorders - Overview *MOST COMMON **MOST LIKELY • Substance-Induced Anxiety Disorder* • Panic Disorder* (having had a panic attack-with or without Agoraphobia) • Posttraumatic Stress Disorder** • Acute Stress Disorder** • Agoraphobia (without history of panic) • Specific Phobia • Social Phobia • Obsessive-Compulsive Disorder • Generalized Anxiety Disorder • Anxiety Disorder Due to a GMC • Anxiety Disorder Not Otherwise Specified JP CounselingHealing for Adults, Youth and Families

5. Anxiety Disorders • Acute Stress Disorder is characterized by symptoms that occur immediately in the aftermath of an extremely traumatic event. • Posttraumatic Stress Disorder (PTSD) is characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma. JP CounselingHealing for Adults, Youth and Families

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7. Posttraumatic Stress Disorder - PTSD Diagnostic Features (adapted from DSM 5) • Response to the event involves intense fear, helplessness, horror - Disorganized or agitated behavior in children • Persistent re-experiencing of the traumatic event - Flashbacks - not substance induced • Recurrent distressing dreams of event - In children, can be frightening dreams without recognizable content • Acting or feeling as if event reoccurring • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of event • Physiological reactivity on exposure to above cues JP CounselingHealing for Adults, Youth and Families

8. Post-Traumatic Stress Disorder • The lifetime prevalence of PTSD among adults in the United States is about 8 percent. • Among high-risk individuals (those who have survived rape, military combat, and captivity or ethnically or politically motivated internment and genocide), the proportion of those with PTSD ranges from one-third to one-half. JP CounselingHealing for Adults, Youth and Families

9. Post-Traumatic Stress Disorder • Among clients in substance abuse treatment, PTSD is two to three times more common in women than in men. • The rate of PTSD among people with substance use disorders is 12 to 34 percent; for women with substance use disorders, it is 30 to 59 percent. JP CounselingHealing for Adults, Youth and Families

10. Post-Traumatic Stress Disorder • Women with substance abuse problems report a lifetime history of physical and/or sexual abuse ranging from 55 to 99 percent. • Most women with this co-occurring disorder experienced childhood physical and/or sexual abuse; men with both disorders typically experienced crime victimization or war trauma. JP CounselingHealing for Adults, Youth and Families

11. Post-Traumatic Stress Disorder • People with PTSD and substance abuse are more likely to experience further trauma than people with substance abuse alone. • Because repeated trauma is common in domestic violence, child abuse, and some substance-using lifestyles (e.g., the drug trade), helping the client protect against future trauma may be an important part of work in treatment. JP CounselingHealing for Adults, Youth and Families

12. Post-Traumatic Stress Disorder • People with PTSD tend to abuse the most serious substances (cocaine and opioids); however, abuse of prescription medications, marijuana, and alcohol also are common. • From the client’s perspective, PTSD symptoms are a common trigger for substance use. JP CounselingHealing for Adults, Youth and Families

13. Post-Traumatic Stress Disorder • While under the influence of substances, a person may be more vulnerable to trauma—for example, a woman drinking at a bar may go home with a stranger and be assaulted. • As a counselor, it is important to recognize, and help clients understand, that becoming abstinent from substances does not resolve PTSD; both disorders must be addressed in treatment. JP CounselingHealing for Adults, Youth and Families

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15. Eating Disorders • The prevalence of bulimia nervosa is elevated in women presenting for substance abuse treatment. • Studies of individuals in inpatient substance abuse treatment centers (as assessed via questionnaire) suggest that approximately 15 percent of women and 1 percent of men had an eating disorder (primarily bulimia nervosa) in their lifetime (Hudson et al) • Substance abuse is more common in bulimia nervosa than in anorexia nervosa. JP CounselingHealing for Adults, Youth and Families

16. Eating Disorders • Individuals with eating disorders are significantly more likely to use stimulants and significantly less likely to use opioids than other individuals undergoing substance abuse treatment who do not have a co-occurring eating disorder. • Many individuals alternate between substance abuse and eating disorders. JP CounselingHealing for Adults, Youth and Families

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18. Suicidality Suicidality is not a mental disorder in and of itself, but rather a high-risk behavior associated with COD, especially (though not limited to) serious mood disorders. Research shows that most people who kill themselves have a diagnosable mental or substance use disorder or both, and that the majority of them have depressive illness. JP CounselingHealing for Adults, Youth and Families

19. Suicide •Cognitive problem-solving styles • Underlying neurobiology • Increased rate often related to substance use/abuse • Mood disorders and SUD increased risk JP CounselingHealing for Adults, Youth and Families

20. SUICIDALITY Teens who use marijuana have 8 times higher rate of suicidal ideation than non-marijuana users and a 16% times higher rate of suicide attempts. JP CounselingHealing for Adults, Youth and Families

21. Suicide • Abuse of alcohol or drugs is a major risk factor in suicide, both for people with COD and for the general population. • Alcohol abuse is associated with 25 to 50 percent of suicides. Between 5 and 27 percent of all deaths of people who abuse alcohol are caused by suicide, with the lifetime risk for suicide among people who abuse alcohol estimated to be 15 percent. JP CounselingHealing for Adults, Youth and Families

22. Suicide • The association between alcohol use and suicide also may relate to the capacity of alcohol to remove inhibitions, leading to poor judgment, mood instability, and impulsiveness. • Substance intoxication is associated with increased violence, both toward others and self. JP CounselingHealing for Adults, Youth and Families

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24. What Counselors Should Know About Mood and Anxiety Disorders and Substance Abuse • Approximately one quarter of United States residents are likely to have some anxiety disorder during their lifetime, and the prevalence is higher among women than men. • About one half of individuals with a substance use disorder have an affective or anxiety disorder at some time in their lives. JP CounselingHealing for Adults, Youth and Families

25. What Counselors Should Know About Mood and Anxiety Disorders and Substance Abuse • Among women with a substance use disorder, mood disorders may be prevalent. Women are more likely than men to be clinically depressed and/or to have posttraumatic stress disorder. • Certain populations are at risk for anxiety and mood disorders (e.g., clients with HIV, clients maintained on methadone, and older adults).

26. What Counselors Should Know About Mood and Anxiety Disorders and Substance Abuse • Older adults may be the group at highest risk for combined mood disorder and substance problems. Episodes of mood disturbance generally increase in frequency with age. Older adults with concurrent mood and substance use disorders tend to have more mood episodes as they get older, even when their substance use is controlled. • Both substance use and discontinuance may be associated with depressive symptoms. JP CounselingHealing for Adults, Youth and Families

27. What Counselors Should Know About Mood and Anxiety Disorders and Substance Abuse • Acute manic symptoms may be induced or mimicked by intoxication with stimulants, steroids, hallucinogens, or polydrug combinations. • Withdrawal from depressants, opioids, and stimulants invariably includes potent anxiety symptoms. During the first months of sobriety, many people with substance use disorders may exhibit symptoms of depression that fade over time and that are related to acute withdrawal

28. What Counselors Should Know About Mood and Anxiety Disorders and Substance Abuse • Medical problems and medications can produce symptoms of anxiety and mood disorders. About a quarter of individuals who have chronic or serious general medical conditions, such as diabetes or stroke, develop major depressive disorder. • People with co-occurring mood or anxiety disorders and a substance use disorder typically use a variety of drugs. JP CounselingHealing for Adults, Youth and Families

29. What Counselors Should Know About Mood and Anxiety Disorders and Substance Abuse • Though there may be some preference for those with depression to favor stimulation and those with anxieties to favor sedation, there appears to be considerable overlap. The use of alcohol, perhaps because of its availability and legality, is ubiquitous. • It is now believed that substance use is more often a cause of anxiety symptoms rather than an effort to cure these symptoms.

30. What Counselors Should Know About Mood and Anxiety Disorders and Substance Abuse • Since mood and anxiety symptoms may result from substance use disorders, not an underlying mental disorder, careful and continuous assessment is essential. • Differentiate between mood disorders, common-place expressions of depression, and depression associated with more serious mental illness. • Conduct careful and continuous assessment since mood symptoms may be the result of substance abuse and not an underlying mental disorder.

31. Screening Screening is a formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular disorder and, in this context, the possibility of a co-occurring substance use or mental disorder. The screening process for COD seeks to answer a “yes” or “no” question: Does the substance abuse (or mental health) client being screened show signs of a possible mental health (or substance abuse) problem? Note that the screening process does not necessarily identify what kind of problem the person might have or how serious it might be, but determines whether or not further assessment is warranted. JP CounselingHealing for Adults, Youth and Families

32. Assessment for ALL Disorders is Necessary Because... •Having one disorder increases the risk of developing another disorder; • The presence of a second disorder makes treatment of the first more complicated; • Treating one disorder does NOT lead to effective management of the other(s); • Treatment outcomes are poorer when co-occurring disorders are present. JP CounselingHealing for Adults, Youth and Families

33. •The person sitting before you has a history before the onset of their presenting symptoms. • The person’s early developmental history holds essential information regarding resiliencies & competencies as well as areas of deficit and risk potential JP CounselingHealing for Adults, Youth and Families

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35. Gathering Data • History and mental status examination • Physical Examination • Self-report • Reports of family, peers, school, legal, etc. • Structured interviews and standardized tests • Laboratory test results • Drug screening JP CounselingHealing for Adults, Youth and Families

36. Archival Records •Collection of prior treatment charts and/or summaries, school records, etc. is usual. • Use of standardized instruments to collect data is not common. • Data bias is more common than not, given the variance in evaluators, client’s presenting problem, domain/purview of assessor. • Such data are useful, but not complete. JP CounselingHealing for Adults, Youth and Families

37. Assessment Time Frames •Recent vs. historical data - Combination generally most useful • Lifetime timelines by key area provides data - what occurred when - developmental impact • Past week data give current functioning • Periods of time during past year give improvement vs. regression data for specific areas of functioning JP CounselingHealing for Adults, Youth and Families

38. ASSESSMENT DOMAINS •history of substance use • medical, family & sexual histories • strengths and resources • developmental issues • mental health history • school, vocational, juvenile justice histories • peer relationships and neighborhood • leisure-time interests, hobbies, activities JP CounselingHealing for Adults, Youth and Families

39. BIOLOGIC MEASURES • Urinalysis and blood-alcohol content • Other biologic measures may be needed (e.g., lithium levels, checking ADHD medication responses, etc.) JP CounselingHealing for Adults, Youth and Families

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42. Screening and Assessment •Routine questions regarding - Depression - Suicidal ideation and behavior - Anxiety - Aggressive behavior - Current and past MH/SU treatment • Questions about psychiatric and behavioral problems should cover every major diagnostic group JP CounselingHealing for Adults, Youth and Families

43. Purposes of Assessment • Establish a working relationship • Engage the client • Demystify the process • Engage Family • Assess Competencies, Capacities & Resiliencies JP CounselingHealing for Adults, Youth and Families

44. Purposes of Assessment • Assess & Evaluate Resistance, Motivation, Readiness for Change • Assess & Evaluate Severity of Illness • Substance Use Disorder • Psychiatric / Mental Health Disorder • Develop Provisional DSM Diagnostic Picture • Develop Provisional Plan of Action • Goals • Objectives JP CounselingHealing for Adults, Youth and Families

45. Other Services Needed • Determine need for multidimensional services • Consider • Living conditions, • Other family issues/needs, • Other agencies already involved/needing to be involved, • What supports will be necessary and must be coordinated in order to support treatment efficacy

46. Purposes for Family Involvement • Learn about client from family perspective • Mutual education and redefinitions • Define substance use in the family context • Establish/re-establish parental influence • To decrease family’s resistance to treatment

47. Family Involvement • To assess interpersonal function of drug use • To interrupt non-useful family behaviors • Identify and implement change strategies consistent with family’s interpersonal functioning and cultural identity • Provide assertion training for children and any high-risk siblings

48. Culturally Competent Treatment • One definition of cultural competence refers to “the capacity of a service provider or of an organization to understand and work effectively with the cultural beliefs and practices of persons from a given ethnic/racial group” • Cultural sensitivity is being “open to working with issues of culture and diversity.” Viewed as a point on the continuum, however, a culturally sensitive individual has limited cultural knowledge and may still think in terms of stereotypes.

49. Culturally Competent Treatment • Cultural competence, when viewed as the next stage on this continuum, includes an ability to “examine and understand nuances” and exercise “full cultural empathy.” This enables the counselor to “understand the client from the client’s own cultural perspective.” • Cultural proficiency is the highest level of cultural capacity. In addition to understanding nuances of culture in even greater depth, the culturally proficient counselor also is working to advance the field through leadership, research, and outreach.

50. Characteristics of Culturally Competent Treatment Programs(Gains Center: Working Together for Change, 2001) • Family (as defined by culture) seen as primary support system • Clinical decisions culturally driven • Dynamics within cross-cultural interactions discussed explicitly & accepted • Cultural knowledge built into all practice, programming & policy decisions • Providers explore person’s level of assimilation/acculturation JP CounselingHealing for Adults, Youth and Families