Co-Occurring Disorders: Part 2

1. Co-Occurring Disorders: Part 2 Melody Kipp, PhD, LMHC Life & Work Soulutions, Inc.

2. Co-Occurring Disorders: Part 2 • Evans, E.K. & Sullivan, J.M. (2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser, (2nd ed.). New York: The Guilford Press.

3. The Psychotic & Cognitive Disorders • “There are those too who suffer from great emotional and mental disorders. They too are able to recover if they have the capacity for honesty.” • Alcoholics Anonymous

4. The Psychotic & Cognitive Disorders • Before you begin this section about schizophrenia, list below your understanding of schizophrenia. For example, answer these questions: • What does a person was schizophrenia look like? • How do they behave?

5. The Psychotic & Cognitive Disorders • Do I have prejudices or stereotypes about people with schizophrenia? • How do I feel interacting with someone with a psychotic disorder? • Do I feel comfortable treating clients with those diagnoses?

6. The Psychotic & Cognitive Disorders • Cardinal features of schizophrenia include substantial impairment of clients’ thought processes as well as the bizarre content of their thoughts.

7. The Psychotic & Cognitive Disorders • Symptoms of schizophrenia as noted in the DSM-IV: • Delusions • Hallucinations • Disorganized speech • Grossly disorganized or catatonic behavior • “Negative” symptoms

8. The Psychotic & Cognitive Disorders • Positive symptoms are a problem because of what is there and negative symptoms are problem because of what is not there.

9. The Psychotic & Cognitive Disorders • Symptoms must be present for at least 6 months. • Symptoms often manifest themselves during late adolescence and early adulthood. • Complete remission is uncommon.

10. The Psychotic & Cognitive Disorders • 5 other psychotic disorders: • Schizophreniform disorder • Schizoaffective disorder • Brief psychotic disorder • Delusional disorder • Psychotic conditions that are substance-induced or due to a medical condition

11. The Psychotic & Cognitive Disorders • Neurological sensitization is when less and less of a drug is needed to provoke the desired response. • Cross sensitization is when responses to other drugs and stressors in general are exaggerated. • How would these events complicate your client’s treatment?

12. The Psychotic & Cognitive Disorders • 3 key issues for managing the person with schizophrenia: • Medication compliance • Marked deficits in role performance • The need for abstinence from alcohol and drugs

13. The Psychotic & Cognitive Disorders • About 50% of people with a diagnosis of schizophrenia also have a substance use disorder. • Even moderate drinking appears to be unsafe for this population • Stressful situations and high demands often cause clients with schizophrenia to disorganize

14. The Psychotic & Cognitive Disorders • Using lots of visual aids and keeping materials simple and concrete will help clients with schizophrenia change their behaviors. • Groups that use classroom methods to teach topical issues are more helpful during treatment than process groups

15. The Psychotic & Cognitive Disorders • What may happen when a person with schizophrenia abuses alcohol and discontinues their medications? • The alcohol further disorganizes them and exacerbates the side effects of their medication.

16. The Psychotic & Cognitive Disorders • Heavy confrontation of the person with schizophrenia who is in denial should be avoided. • Slowly and painfully build into the clients’ worldview that he/she is chemically dependent and cannot use drugs or alcohol at all, ever, under any circumstances.

17. The Psychotic & Cognitive Disorders • Going quickly through the 12 steps of recovery with a person with schizophrenia is an unrealistic expectation. • Personal therapy is most likely to benefit clients with schizophrenia to prevention relapse.

18. The Psychotic & Cognitive Disorders • 3 phases of Personal Therapy • Phase 1 involves supportive counseling, psychoeducation, problem-solving, social skills practice, and medication management. • Phase 2 involves identifying individual indicators of negative affect and skills, such as relaxation techniques, to manage negative feelings, as well as continued social skills training.

19. The Psychotic & Cognitive Disorders • Phase 3 involves social and vocational initiatives in the community, awareness of triggers for problems and other self-monitoring skills, and work on clients’ social impact on others • Clients not living with families or in a stable living situation will not benefit from Personal Therapy.

20. The Psychotic & Cognitive Disorders • Do not expect miracles, but do not leave prematurely. ??? • The term Cognitive Disorders refers to: • Delirium, dementia, and amnesic disorders

21. The Psychotic & Cognitive Disorders • Cognitive disorders are associated with: • A significant deficit in cognition or memory that represents a change from previous functioning. • A general medical condition, a substance, or some combination of the 2 may cause a cognitive disorder

22. The Psychotic & Cognitive Disorders • Memory difficulties and other cognitive impairments as well as profound personality deterioration are the essential features of dementia.

23. The Psychotic & Cognitive Disorders • Abstinence is the only goal for the person with a cognitive disorder. • Keeping the step work concrete and simple will help in the treatment of someone dually diagnosed with a cognitive disorder.

24. The Affective & Anxiety Disorders • Bipolar disorder is the more recent term for manic depression. • The distinctive features of bipolar disorder are: • A distinct period of extreme swings of mood ranging from manic euphoria and hyperactivity to depressed sadness and immobility.

25. The Affective & Anxiety Disorders • Hypomania is defined as having only mild highs. • The first criterion for bipolar disorder is a distinct period of abnormal and persistently elevated, expansive, or irritable mood lasting at least one week.

26. The Affective & Anxiety Disorders • The other symptoms a person may exhibit during the manic phase are: • Inflated self-esteem • Decreased need for sleep • Greater talkativeness than usual or pressure to keep talking

27. The Affective & Anxiety Disorders • Flight of ideas or racing thoughts • Distractibility • Increase in goal-directed activity or psychomotor agitation • Excess of involvement in pleasurable activities that potentially have negative consequences such as buying sprees or promiscuity.

28. The Affective & Anxiety Disorders • The difference between Bipolar I and Bipolar II is: • Bipolar I type refers to classic manic-depressive illness. Bipolar II type involves a history of one or more episodes of major depression accompanied by at least one hypomanic episode.

29. The Affective & Anxiety Disorders • 3 key treatment issues people suffering with bipolar disease encounter are: • Medication compliance. • A need for a balanced lifestyle, with a reasonable mixture of work, play, love, and proper attention to nutrition and exercise. • Abstinence from all substance use or abuse.

30. The Affective & Anxiety Disorders • What do mania and chemical dependency have in common? • Both are out-of-control behaviors. • Hospitalization may become necessary to stabilize behavior and ensure initial abstinence for someone with bipolar when the mania is acute.

31. The Affective & Anxiety Disorders • Manic behavior may be redirected to something positive, such as taking notes, during treatment. • What other ways can you think of to redirect manic behavior?

32. The Affective & Anxiety Disorders • The recovery approach can help clients deal not only with their chemical dependency but also their bipolar illness. • Both are diseases, both involve issues of out-of-control behavior, and both provide a way of doing grief work and repairing the personal and interpersonal damage associated with these diseases.

33. The Affective & Anxiety Disorders • Sensation-seeking and impulsive use should be the focus for a person with bipolar disorder when planning for relapse. • There is hope for people with bipolar disease to recover well and maintain abstinence from substance abuse.

34. The Affective & Anxiety Disorders • Symptoms of ADHD can sometimes mimic the symptoms of mania. • A comprehensive drug/alcohol assessment is now required by many school districts in assessing ADHD in students.

35. The Affective & Anxiety Disorders • Using stimulants to treat ADHD should be avoided if the client is also suffering from a disease of addiction. • Antidepressants are an alternative to using stimulants to treat ADHD.

36. The Affective & Anxiety Disorders • The cardinal feature of Major Depression is feeling deeply sad, down, or having an irritable mood. • What are the other symptoms of major depression as indicated by the DSM-IV? (Must have at least 5 of the following for at least 2 weeks)

37. The Affective & Anxiety Disorders • A depressed or irritable mood most of the day, nearly every day. • Markedly diminished interest or pleasure. • Significant weight lost while not dieting or significant weight gain.

38. The Affective & Anxiety Disorders • Insomnia or hypersomnia. • Psychomotor agitation or retardation nearly every day. • Fatigue or loss of energy nearly every day.

39. The Affective & Anxiety Disorders • Feelings of worthlessness or excessive or inappropriate guilt. • Diminished ability to think or concentrate, or indecisiveness. • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

40. The Affective & Anxiety Disorders • Dysthymia is a chronic low-grade depression. • The following are symptoms of dysthymia: • A depressed or irritable mood for most of the day, for more days than not for at least 2 years. • Poor appetite or overeating.

41. The Affective & Anxiety Disorders • Insomnia or hypersomnia. • Low-energy or fatigued condition. • Low self-esteem. • Poor concentration or difficulty making decisions. • Feelings of hopelessness.

42. The Affective & Anxiety Disorders • Approximately 33% of people with a lifetime history of major depression also have a lifetime history of a substance use disorder.

43. The Affective & Anxiety Disorders • For those with substance use disorders, the following factors are likely to be causally linked to the development of major depression: • Low self-esteem • Chronic stress • Severely threatening life events

44. The Affective & Anxiety Disorders • A positive family history of major depression • The perception of having no control in one's life • External attribution for positive and negative events • Sleep abnormalities

45. The Affective & Anxiety Disorders • Negative life events not only can trigger a major depression, but a major depression can create negative life events in a vicious cycle.

46. The Affective & Anxiety Disorders • The following types of treatment are suggested for the following types of depression: • Mild depression: psychotherapy. • Moderate to severe depression: a combination of medication and psychotherapy plus ongoing maintenance treatment of monthly counseling sessions and medication follow-up as needed.

47. The Affective & Anxiety Disorders • You should refer the client who presents with serious suicidal ideation for a medication evaluation to a qualified psychiatrist.

48. The Affective & Anxiety Disorders • People with Major Depression show significant cognitive impairments; and those in early addiction recovery also show cognitive impairments. • Be prepared to engage in some very basic and extensive problem-solving with your depressed dually diagnosed client. • Target, in particular, relationship and job issues.

49. The Affective & Anxiety Disorders • How can you help those clients remember the solutions and tasks you agreed upon during your session? • Write them down. • Symptoms of anxiety very commonly accompany major depression and require attention.

50. The Affective & Anxiety Disorders • Why do you believe that helping a client to build or rebuild their social support system would help their levels of depression? • Why do you think that the hopelessness that accompanies major depression might lead to relapse?