Psychiatric Aspects of Adolescent Co-occurring Disorders Seth Eisenberg MD Medical Director, DHS-DASA October 24, 2011
Eisenberg Outline • Similarities and relationships between AOD and psych symptoms • Mental Status Exam, Diagnosis and Psychiatric Symptoms • Anxiety Disorders • Elements of Medication Treatment • Adolescent Gambling • Ask the Doc
AOD Use and Psychiatric Symptoms AOD use can cause psychiatric symptoms and mimic psychiatric syndromes. AOD use can initiate or exacerbate a psychiatric disorder. AOD use can mask psychiatric symptoms and syndromes. AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes. Psychiatric and substance use disorders can independently coexist. Psychiatric behaviors can mimic substance use problems. SAMHSA TIP #9
Adolescent Dependency GENERAL EFFECTS The adolescent demonstrating these behaviors may be indicating a problem with drugs and/or alcohol: • Sudden, noticeable personality changes • Severe mood swings • Changing peer groups • Dropping out of extra-curricular activities ADOL-CD Cont’d
GENERAL EFFECTS • Decreased interest in leisure time activities • Worsening grades • Irresponsible attitude toward household jobs and curfews • Depressed feelings much of the time • Dramatic change in personal hygiene concern • Changes in sleeping or eating habits ADOL-CD Cont’d
GENERAL EFFECTS • Smell of alcohol or pot • Sudden weight loss • Tendency toward increasing dishonesty • Trouble with the law • Truancy from school ADOL-CD Cont’d
GENERAL EFFECTS • Frequent job losses or changes • Turned off attitude if drugs are discussed • Missing household money or objects • Increasing time alone in his/her room ADOL-CD Cont’d
GENERAL EFFECTS • Deteriorating family relationships • Drug use paraphernalia, booze, or empty bottles found hidden • Observations of negative behavior by people within or outside immediate family • Obvious signs of physical intoxication ADOL-CD Cont’d
GENERAL EFFECTS Some of these behaviors are a sign of typical adolescent development, BUT, a wide variety of them in one person should raise suspicions of the likelihood of harmful involvement with drugs or alcohol…. OR—some kind of psychiatric problem ADOL-CD Cont’d
Adolescent Comorbidity The syndrome most consistently associated with substance use is delinquent behavior, followed by scales measuring social problems and attention problems
Adolescent Comorbidity The likelihood of substance use among adolescents is associated with the severity of emotional and behavioral problems across age and gender groups.
Adolescent Comorbidity Past-month marijuana use was nearly 2x as likely and use of other drugs was 4x more likely for adolescents with serious emotional problems than for adolescents with low levels of emotional problems.
Adolescent Comorbidity Past-month marijuana use was 4x as likely, and use of other drugs was nearly 7x more likely, for adolescents with serious behavioral problems than for adolescents with low levels of behavioral problems.
Adolescent Comorbidity Dependence on substances such as cocaine, crack, inhalants, hallucinogens, heroin or prescription drugs was nearly 9x as likely among adolescents with serious behavioral problems.
Adolescent Comorbidity Past-month alcohol use was nearly 2x as likely for adolescents with serious emotional problems than for adolescents with low levels of emotional problems.
Adolescent Comorbidity Adolescents with serious behavioral problems were nearly 3x as likely to use alcohol in the past month than adolescents with low levels of behavioral problems
Adolescent Comorbidity Adolescents with serious emotional problems were nearly 4x more likely to be dependent on alcohol or illicit drugs than adolescents with low levels of emotional problems.
Adolescent Comorbidity Alcohol or drug dependence was more likely among adolescents with serious behavioral problems than among adolescents with low levels of behavioral problems
Adolescent Comorbidity Stealing, swearing, hanging around with troublemakers and running away from home - Feeling confused or in a fog were associated with more substance use
Adolescent Comorbidity While overall substance use is generally higher for adolescent males than for females, females with high ratings for psychosocial problems as measured by the YSR were as likely as males to smoke cigarettes, binge drink or use illicit drugs.
Adolescent Comorbidity Risk Factors • Juvenile Delinquency • Runaways • High School Dropouts • Youth With Psychiatric Disorders • Unmarried Pregnant Adolescents • Youth That Have Been Physically, • Sexually, or Emotionally Abused
Adolescent Comorbidity Risk Factors • Unsatisfactory Family Relations • Children in Foster Care • Extreme Sexual Activity • Exploited Youth • School Difficulty - Low G.P.A.
Adolescent Comorbidity Risk Factors • Family Social Deprivation, i.e., Poverty • Association with Delinquent Peers • Neighborhood/Community • Disorganization • Affiliation with Peers of Other • Dysfunctional Family Systems
Adolescent Comorbidity Characteristic Profile • More Impulsive • Less Mature • More Peer Oriented • Restless (tension reduction oriented)
Adolescent Comorbidity Characteristic Profile • Rebellious • Increased Sadness • Increased Social Withdrawal • Learning Problems
Adolescent Chemical Dependency Individual Risk • Low self esteem • Feelings of not belonging • Poor coping skills • Poor interpersonal skills • Poor situational skills, poor judgement • Biogenetic factors ADOL-CD Cont’d
Adolescent Comorbidity When Compared to Non-CD Psychiatric Cases • Earlier First Use of Drugs (14 vs 12) • Increased Divorce (56% vs 26%) • Increased Parental CD • Increased Parental Psychiatric Illness
Adolescent Comorbidity When Compared to Non-CD Psychiatric Cases • More Legal Problems • Increased Special Education Placement • More Frequent Suicide Attempts • Increased Residential Placement
Adolescent Comorbidity Associated with: • Earlier Onset of Abuse Behaviors • Greater Clinical Severity • Poorer Outcomes • Increased Disturbance of Relationships
Adolescent Comorbidity Associated with: • Differential Responsiveness to CD • Treatment • Increased Risk of Relapse • Less than Optimal Functioning when • Abstinent
Adolescent Comorbidity Diagnostic Considerations • Impact of Chemical Use • decreased withdrawal symptoms • varied expression of use • negative effect on development • Emerging Psychiatric Illness • usual age of onset • precipitating event
Adolescent Comorbidity Diagnostic Considerations • Commonality of Symptoms of Psychiatric Disorders • ADHD, bipolar, depression, CD, anxiety • Confounding Symptoms of Adolescent CD • Intoxication • Chronic use • ABCD-S
Adolescent Comorbidity Adolescent Behavior CD Syndrome • High Delinquency • Hyperactivity • Decreased School Performance • Decreased Social Competence/Participation • Depressed Behaviors • Onset after development of CD and • subsides 2 months after onset of sobriety
Adolescent Comorbidity ABCD-S (Continued) • May Result In: • developmental dysfunction • hyperactivity, distractibility • restlessness, impulsivity • depression and suicide • Possible Overdiagnosis of Psychiatric • illness
Diagnostic Dilemmas • Psychoactive substances have profound effects on neurotransmitter systems • Neurotransmitters may be involved in psychiatric disease states • May unmask genetic vulnerability • May cause a psychiatric disease • It may be difficult to differentiate which diagnosis is primary, ie which “came first”
Psychiatric Diagnosis Mental Status Exam and Psychiatric Symptoms
MENTAL STATUS EXAMINATION (MSE) Formal or MINI MSE ORIENTATION MEMORY CONCENTRATION INSIGHT JUDGMENT IMPULSE CONTROL APPEARANCE SPEECH EMOTIONS (mood & affect) THOUGHT PROCESS THOUGHT CONTENT PERCEPTIONS
MENTAL STATUS EXAMINATION (MSE) Appearance • Physical appearance, mannerisms, attitude Speech • Rate, rhythm, volume, articulation Mood • “how do you feel today” Affect • Outward expression of inner mood: range, intensity, stability, appropriate
MENTAL STATUS EXAMINATION (MSE) Thought Process • Productivity, continuity, coherence Thought Content • fears, obsessions, paranoia, suicide, violence Perceptions • Hallucinations and illusions, depersonalization Orientation and Cognition (formal MSE)
Overview of Psychiatric Disorders and Symptoms • Schizophrenia and Psychosis • Mood Disorders • Anxiety Disorders • ADHD and Impulse Control Disorders • Personality Disorders • Developmental Disorders • Sleep Problems
Schizophrenia and Other Psychotic Disorders • Schizophrenia • Schizophreniform • Schizoaffective Disorder • Delusional Disorder • Brief Psychotic Disorder • Substance Induced Psychotic Disorder
Symptoms of Psychosis • Hallucinations • Delusions (bizarre and non-bizarre) • Disorganized speech • Disorganized thinking • Disorganized behavior or catatonia • “negative symptoms”
chlorpromazine fluphenazine haloperidol perphenaxzine thioridazine thiothixene trifluoperazine Thorazine, Prolixin, Haldol (decanoate), Trilafon, Mellaril, Navane, Stelazine Antipsychotics/NeurolepticsTraditional—First Generation
aripiprazole clozapine olanzapine quetiapine risperidone ziprasidone Abilify, Clozaril, Zyprexa (zydis), Seroquel, Risperdal Geodon, Saphris, Fanapt, Latuda Consta Invega Sustena Relprev Antipsychotics/NeurolepticsAtypical, Novel—Second Generation
Mood Disorders • Depressive Disorders • Major Depressive Disorder • Dysthymic Disorder • BiPolar Disorders • Bipolar I • Bipolar II • Cyclothymic Disorder • Substance Induced Mood Disorder
Symptoms of Depression • Depressed mood, sadness, crying • Decreased interest and pleasure • Decreased energy and activity • Weight change, sleep change • Low self esteem, worthlessness, guilt • Decreased concentration • Suicidal ideation
ADOLESCENTCOMORBIDITY Depression • Mostly studied - high prevalence in adults • Approximately 80% clear in two weeks • In adolescents - frequent suicidality • Suicide attempts with increased medical • seriousness and lethality • Family history important • Developmental history important
citalopram escitalopram fluoxetine fluvoxamine paroxetine setraline Celexa, Lexapro, Prozac, Prozac weekly, Sarafem Luvox, Paxil, Paxil CR, Zoloft Cymbalta, Pristiq, Paxeva AntidepressantsSSRIs
amitriptyline clomipramine desipramine doxipin imipramine maprotiline nortriptyline protriptyline Elavil, Anafranil, Norpramin, Sinequan, Tofranil, Ludiomil, Pamelor, Vivactil AntidepressantsTricyclics