comorbidity of substance use disorders and psychiatric ... · 1/25/2011 · comorbidity of...

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HIV NEUROBEHAVIORAL RESEARCH PROGRAMS | UNIVERSITY OF CALIFORNIA, SAN DIEGO

Comorbidity of Substance UseDisorders and

Psychiatric Conditions-2

J. H. Atkinson, M.D.Professor of Psychiatry

HIV Neurobehavioral Research ProgramsUniversity of California, San Diego

KETHEA, Athens, January 25, 2011Slides courtesy of Marc A. Schuckit, M.D.


DIAGNOSIS IS THE KEY TO:

PrognosisPrognosis

TreatmentTreatment


WHEN 2+ DISORDERS ARE OBSERVED:

Which one(s) should be treated?Which one(s) should be treated?

What is best therapy?What is best therapy?

Will disorders and/or treatmentsinteract?


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COMORBIDITY IS COMMON IN SUD

BUT

2/3 have 2nd diagnosis2/3 have 2nd diagnosis

Most are ASPD and other SUDMost are ASPD and other SUD

Many others are organicMany 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 symptomsDrugs can cause psychiatric symptoms

These last days to weeksThese last days to weeks

They clear spontaneouslyThey clear spontaneously

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DRUG INDUCED STATES

Depression Anxiety Psychosis

Which one(s) should be treated?Which one(s) should be treated?

What is best therapy?What is best therapy?




CLASSES OF DRUGS MOST LIKELY TOPRODUCE 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 onesymptom

2) Be sure the class of drugs can cause thatsyndrome

3) Evaluate Independence using a Timelinea) Determine age of onset of the dependenceb) See if the full psychiatric syndrome was seen before the

dependencec) Determine longer-term abstinence periodsd) See if the full psychiatric syndrome was seen during that

periode) Observe person for ~ 4 weeks of abstinence

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DSM IVMAJOR DEPRESSIVE EPISODE

A. Two Weeks of eitherA. Depressed MoodB. Loss of Interest or Pleasure

B. Five or more of the following symptomspresent during the same two weeks nearlyevery day

A. Weight loss or gain of 5% of body weight in the last month, ordecrease or increase in appetite

B. Insomnia or excessive sleepC. Severe restlessness or being slowed down nearly every day as

observed by othersD. Fatigue or loss of energyE. Feelings of worthlessness or excessive guiltF. Decreased ability to think or concentrate, or indecisivenessG. 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 intended4. Inability to, or persistent desire to, cut down or control

use5. A great deal of time spent obtaining, using, or

recovering from use6. Important activities given up or reduced7. Use despite recognition of associated physical and/or

psychological problems

*Dx: “with Physiological Dependence”


ALCOHOL CAUSES DEPRESSION

Acute Alcohol Challenges Chronic Alcohol Experiments Alcoholics

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DEPRESSION AMONG STIMULANT ANDDEPRESSANT ABUSERS

Syndrome %

Moderate Depression 80

Severe Depression 30-40

2+ Week Depression 30

Independent Depression 5-15


Hamilton Depression

Score > 20 (percent)

Weeks

40

20

30

10

0

1 2 4 163


Time Line Example

Major depressive episodes

27 33 33.5X X

Onset of alcoholdependence

6-monthperiod of

abstinence*

Birth40 years

Can monitor with state markers, toxicologyscreens, other informants

*

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TREATMENT

1. Address Symptoms Acutely2. Educate and Reassure3. Evaluate Timeline4. Reserve Antidepressants for

MDD and Lithium, etc. for Bipolar Disorder


ACCESS TO TREATMENT

Philosophy Integrate Begin New Use All Resources


MANIC EPISODE

A. Abnormal + Persistent Elevated or IrritableMood 1+ Week

B. 3+ of : Grandiose, SleepNeed, Talkative, Flight Ideas,

Distractability, Activity, Pleasure Seek

C. Impaired Functioning

Dr Atkinson – I couldn’t figure out how this was supposed to layout…

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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 1stclustered

2. Ages at which abstinence of 3+ monthsoccurred

3. Ages of other major disorders4. Unless substance and other psychiatric

disorders are clearly separate, assume thatpsychiatric problems will clear.

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NERVOUSNESS VS PATHOLOGICALANXIETY

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

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171 PRIMARY ALCOHOLICS

Syndrome %

Withdrawal palpitations and/orshortness of breath 80

Panic while drinking 4

Panic while sober 2

Generalized anxiety whilesober 4


_X Spielburger State Anxiety

40

0

30

1 2 3 4 16Weeks

--------------------------------------------------------------------

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FOR ANY SEVERE IMPAIRMENT

Treat all emergencies Educate Reassure Behavioral Rx Cognitive Rx

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DRUGS OF ABUSE

Exacerbate Prior Psychiatric Disorders byIncreasing:» Mood Swings» Anxiety» Paranoia» Hallucinations» Confusion


OTHER TREATMENT ISSUES

Housing Cognitive/Behavioral Specific Self-Help Groups Staffing Training Staff Therapeutic Communities


Diagnostic ProcessCase Examples

Expected effects of intoxicationand withdrawal Primary psychiatric disorder Substance induced disorders

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Expected Effects of Intoxication andWithdrawal-1

Alcohol, Stimulant and Opioid Intoxication

» Elevated Mood» Depressed Mood» Loss of interest» Insomnia» Restlessness» Poor Concentration


Expected Effects of Intoxication andWithdrawal-2

Alcohol, Stimulant, Nicotine and Opioid Withdrawal

» Anxiety» Irritability» Restlessness» Depressed Mood» Sleep Problems» Appetite Changes


CannabisWithdrawal Symptoms(Budney et al ., 1999)

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Primary depression before andafter substance abuse

GEORGE AND JOAN

Case Examples


George - 1

Primary Depression Beginning Before Substance


George - 2

Primary Depression Beginning Before Substance

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Joan - 1

Primary Depression Continuing After Substance


Joan - 2

Primary Depression Continuing After Substance


Substance-Induced majordepressive syndrome

AL

Case Examples

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Al - 1

Substance-induced major depressive syndrome


Al - 2



Al - 3


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Al - 4



Expected effects of alcohol:Insomnia

RENEE

Case Examples


Renee - 1

Expected effects of alcohol: Insomnia

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Renee - 2



Renee - 3



Renee - 4


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Expected effects of alcohol:Symptoms

BOB

Case Examples


Bob - 1

Expected effects of alcohol: Symptoms


Bob - 2


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Bob - 3



Bob - 4




DOUG

Case Examples

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Doug - 1

Substance-induced depressive symptom: concentration


Doug - 2



Doug - 3


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Doug - 4




SUSAN

Case Examples


Susan - 1


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Susan - 2



Susan - 3



Susan - 4


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QUESTIONS?


Thank you

comorbidity of substance use disorders and psychiatric ... · 1/25/2011 · comorbidity of...

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