Co-occurring Disorders The Mix of Meds and Therapy Illinois Department of Human Services Cross Divisional Training February 19, 2008 Seth Eisenberg MD

Co-occurring DisordersThe Mix of Meds and Therapy

Illinois Department of Human Services Cross Divisional Training

February 19, 2008Seth Eisenberg MD

About Me• Psychiatric Residency in San Francisco• Child Psychiatry--Adolescent CD• Community Mental Health, Marin

County Jail-- De-Institutionalization • Hawaii—Adol. CD, private sector (ice)• Charter Hospital NW Indiana (PG), • Interventions, WTC, MPG, CAP, TASC• DASA medical director • Northwestern—fellowship, in-patient

Co-occurring DisordersThe Mix of Meds and Therapy

Agenda Topics

• Working with COD—Attitudes of Clinicians

• Meds for Anxiety and Mood Disorders

• Medication Treatment—General Principles

• Integrated Tx for Anxiety and Alcohol

• Talking to Patients about Medications

• “Skeptical Attunement”

DUAL DIAGNOSISComplications of Comorbidity

• Increased Severity of Symptoms• Increased Psychiatric Hospitalization• Increased Use of Emergency Services• Increased Violent and Suicidal Behavior

DUAL DIAGNOSISPoor Psychosocial Adjustment

• Increased Homelessness

• Increased Unemployment

• Increased Vocational Disability

• Lack of Social Support Systems

• Earlier Age of Onset

• Treatment Chronicity

Attitudes and Values for Clinicians

• Patience, perseverance, and therapeutic optimism

• Ability to employ diverse theories, concepts, models and methods

• Flexibility of approach

• Cultural competence

• Belief that all individuals have strengths and are capable of growth and development

Six Guiding Principles in Treating Clients with COD

1. Employ a recover perspective2. Adopt a multi-problem viewpoint3. Develop a phased approach to treatment4. Address specific real-life problems early in

treatment5. Plan for the client’s cognitive and

functional impairments6. Use support systems to maintain and

extend treatment effectiveness

Recovery Perspective

• Assess clients stage of change

• Treatment stage (or expectations) should be consistent with stage of change

• Use client empowerment to enhance motivation

• Foster continuous support

• Provide continuity of treatment

• Recognize that recovery is a long-term process and support small gains

Therapeutic Alliance

• Demonstrate understanding and acceptance

• Help client clarify nature of the difficulty

• Indicate you and client will be working together

• You will be helping client help themselves

• Express empathy and willingness to listen to the clients view of the problem

• Assist client to solve some external problems directly and immediately

Using an Empathic Style

An Empathic Style

• Communicates respect for and acceptance of clients and their feelings

• Encourages a nonjudgmental, collaborative relationship

• Allows the clinician to be a supportive and knowledgeable consultant

Using an Empathic StyleAn Empathic Style

• Compliments and reinforces the client whenever possible

• Listens rather than tells

• Gently persuades, with the understanding that the decision to change is the client’s

• Provides support throughout the recovery process

Successful Therapeutic Relationships

• Use a therapeutic alliance to engage

• Maintain a recovery perspective

• Use supportive and empathic counseling

• Manage countertransference

• Monitor psychiatric and SUD symptoms

• Employ culturally appropriate methods

• Increase structure and support

Anxiety Disorders and SUDPrevalence

• 18% with SUD--at least one anxiety disorder

• 15% with AD had at least one SUD

• Treatment seekers for AUD—23-69% w AD

• Treatment seekers for SUD—50% w AD

• Treatment seekers for AD—12% w AUD

• Treatment seekers for AD—7% w SUD

Clear need for cross discipline screen, assessment and treatment

Anxiety Disorders and SUDExplanatory Models

• Secondary substance use model– Self medication: substance interacts with

psychiatric disturbance to make use compelling in susceptible individuals

– Ongoing use leads to development of SUD

• Secondary psychopathology model—SUD leads to the development of psychiatric d/o– Substance use may sensitize neurobiological

stress systems and lead to higher level of vulnerability to PTSD systems after trauma


• Common factor model – underlying genetic or physiologic liability– anxiety sensitivity: tendency to interpret

feelings of anxiety as dangerous

• Bi-directional model– Both the SUD and anxiety disorder play a

role in either developing or maintaining each other

– Social phobic uses alcohol, develops more problems, increased anxiety and more ETOH


• Self Medication Hypothesis– People with anxiety and SUD would report

that they use substances to manage anxiety– People with more severe anxiety would be at

increased risk for SUD– Anxiety would precede substance use– Substances used by people with anxiety and

SUD would be anxiolytic

Panic Attack

• Palpitations, pounding, chest pain/discomfort

• Sweating

• Trembling or shaking

• SOB

• Feeling of choking

• Nausea or abdominal distress

• Dizzy, unsteady, lightheaded or faint

• Derealization, depersonalization

• Fear of losing control, going crazy, dying

Panic Disorder

“The presence of recurrent, unexpected panic attacks followed by persistent concern about

having another panic attack.” (DSM IV)

1.5% - 3.5% Lifetime prevalence Panic attacks may be induced by

substance use With or without agoraphobia TCAs and SSRIs

Block panic attacks Start with low doses

Latency of onset - use of benzodiazepines

Agoraphobia

• Anxiety about being in places or situations from which escape might be difficult (or embarrassing) in the event of a panic attack

• The situations are avoided or are endured with marked distress

• Anxiety or phobic avoidance is not better accounted for by another mental disorder

Anxiety Disorders and SUDMedication Treatment

Panic Disorder (5-42% in AUD, 7-13% in MMT)

• SSRI, TCA, MAOI, benzodiazepines all effective (not studied in COD populations)

• May have initial activation with SSRI and TCA that could increase risk of relapse—use low dose initiation

• Latency of onset of effect, 2-6 weeks

• SSRIs—no abuse potential, safe, generally well tolerated, may help with ETOH


• Benzos usually avoided in SUD populations (but not an absolute contraindication)

• Panic disorder can also be treated with anticonvulsants (valproate or carbamazepine) and Panic with stimulant abuse may respond to these agents due to neuronal sensitization and limbic excitability

• TCAs carry risk of lower seizure threshold and interactions with ETOH, depressants and stimulants

Social Phobia

• Marked and persistent fear of social or performance situations, possible scrutiny by others or may act in a way that will be embarrassing or humiliating

• Exposure to feared social situation provokes anxiety (or may have panic attack)

• Person recognizes that the fear is excessive• Feared situations are avoided or endured• Avoidance, anxious anticipation or distress

interferes with functioning


Social Anxiety Disorder (8-56% in AUD, 14% in cocaine, 6% in MMT)

• In most cases SAD precedes AUD so a period of abstinence not so important

• Early identification important with COD as SAD may interfere with SUD treatment

• SSRI have FDA indication (paroxetine) and may also reduce alcohol use

• Venlafaxine and gabapentin

Generalized Anxiety Disorder

• Excessive anxiety and worry (apprehensive expectation) about number of events occurring more days than not

• Difficult to control the worry• Associated with three or more frequently present

– Restlessness or feeling keyed up, on edge– Easily fatigued, – Irritability– difficulty concentrating or mind going blank– Muscle tension– Sleep disturbance


Generalized Anxiety Disorder (8-52% in AUD, 21% in MMT, 8% in cocaine)

• Diagnostic difficulties—overlap with symptoms of acute intoxication with stimulants and withdrawal from alcohol and sedatives (and anxiety in early recovery)

• SSRI, TCA, venlafaxine, anticonvulsants

• Use of benzodiazepines is controversial

• Buspirone may be effective

Mood Disorders

• Depressive Disorders– Major Depressive Disorder– Dysthymic Disorder

• BiPolar Disorders– Bipolar I– Bipolar II

• Cyclothymic Disorder

• Substance Induced Mood Disorder

Affective Illness and CD

1. Convincing history of affective disorder previously diagnosed, ideally during abstinence, with historical indications of expected medication response if medicated.

2. Depression is a normal feeling state in early sobriety.

3. Mania must be distinguished from anxiety and chronic ADHD.

4. Positive family history is suggestive.

5. Seek historical evidence of episodic mood alterations that last for weeks/months and are independent of events.

Affective Illness and CD(continued)

Depressive Disorders and CD

• 5% - 25% up to 90%• Varied time for improvement based

on substance• Depression part of recovery process• Abuse of TCAs in methadone clinics,

elevated blood levels• Activating effect, cardiotoxicity• SSRIs better tolerated, safer,

decreased drinking

Medications for Bipolar and SUD

• Bipolar with SUD—56% (ECA), most common Axis I

• SUD assoc. w poor prognosis in Bipolar– More hospitalizations for affective episodes– Affective sx earlier in life– More depressive or mixed episodes

• COD w increased time to med treatment

• Increased risk for antidepressant induced mania


• Lithium may be less effective in COD– May be useful in adolescents with COD

• More responsive to anticonvulsants– “Kindling”—neuronal sensitization in alcohol

withdrawal and cocaine intoxication– Valproate (may also decreased drinking)– Carbamazepine (helpful with cocaine)– Generally safe—monitor liver and blood count

• topiramate helpful in alcohol dependence


• lamotragine—helped with cocaine

• Gabapentin—may help with alcohol/anxiety

• Atypical antipsychotics– Seroquel—mood, alcohol, anxiety– others

Ask the Doc

Medication Treatment of Psychiatric and Substance Use

Disorders

Psychotherapeutic Medications: What Every Counselor Should Know

Mid-America Addictions Technology Transfer Center

Medication TreatmentGeneral Principles

Pharmacologic effects:• Therapeutic—indicated purpose and

desired outcome• Detrimental—unwanted side effects (may

interfere with adherence), potential for abuse and addiction

Need a balance between therapeutic and detrimental


Psychoactive Potential: Ability of some medications to cause distinct change in mood or thought and psychomotor effects– Stimulation, sedation, euphoria– Delusions, hallucinations, illusions – Motor acceleration or retardation

All drugs of abuse are psychoactive


• Many medications are non-psychoactive (except for mild side effects including sedation or stimulation)

• Not considered euphorigenic( although can be misused and abused)

• Psychoactive drugs considered high risk for abuse and addiction

• Some psychoactive meds have less addiction potential (old antihistimines)


Positive reinforcement—increase the likelihood of repeated use– Amplification of positive symptoms or states– Removal of negative symptoms or conditions– Faster reinforcement, more prone to misuse

Tolerance and Withdrawal– Higher risk for abuse and addiction

More concerns when prescribing to high-risk patients

Medication TreatmentStepwise Treatment Model

• Risks/benefits analysis (risk of medication, risk of untreated condition, interactions, potential for therapeutic benefits)

• Early and aggressive treatment of severe psychiatric problems

• Start with more conservative approach with high risk patients and less severe conditions


High risk patients with anxiety disorder1. Non-pharmacologic approaches when

possible

2. Non-psychoactive medications added next as adjunctive treatment

3. Psychoactive medications when other treatments fail


• Non-pharmacologic approaches– Psychotherapy, cognitive and behavioral tx,

stress management skills, medication, exercise biofeedback, acupuncture, education, etc

• Use meds with low abuse potential

• Conservative approach not the same as under-medicating

• Different treatments should be complementary, not competitive

Which to treat first: Comorbid anxiety or alcohol disorder?

Current Psychiatry

Vol. 6 No.8/Aug 2007Kushner, et al.

Comorbid Anxiety and Alcohol Which Comes First?

Generalized Anxiety Disorder (8-52% in AUD, 21% in MMT, 8% in cocaine)

• Diagnostic difficulties—overlap with symptoms of acute intoxication with stimulants and withdrawal from alcohol and sedatives (and anxiety in early recovery)

• SSRI, TCA, venlafaxine, anticonvulsants

• Use of benzodiazepines is controversial

• Buspirone may be effective

Comorbid Anxiety and Alcohol Which Comes First?

• Risk of getting new ETOH Dep as a Jr/Sr more that tripled among students with anxiety dx as a freshman.

• Students with ETOH Dep as freshman were 4xmore likely to dev. an anxiety d/o (6yrs)

• So having either an anxiety or ETOH d/o earlier in life apears to increase the probability of developing the other later

Comorbid Anxiety and Alcohol Treatment Approaches

• Serial (sequential) approach—treatment comorbid disorders one at a time

• Parallel approach—providing simultaneous but separate treatments for each comorbidity

• Integrated approach—providing one treatment that focuses on both comorbid disorders, especially as they interact with one another

• Tx determined by clinical and resources


Serial Treatment—treat disorder one at a time• May help empirically evaluate whether the

untreated condition is resolved by treating other• Allows use of established treatment resources• Initially untreated comorbid disorder could

undermine resolution of the treated disorder. • Not always clear which disorder to treat first—may

depend on presenting symptom• Tx with meds for anxiety and then address ETOH

with brief intervention


Parallel Treatment—simultaneous/separate

• may be less common in MH settings

• Requires coordination of clinicians, tx strategies, times, locations

• Impact of other disorder not appreciated

• MH vs SUD treatment programs may have conflicting values


Integrated Treatment—one treatment plan (or one tx) for both disorders (not many)

• CBT-based integrated approach– Psychoeducation– Cognitive restructuring– Cue exposure

Comorbid Anxiety and Alcohol CBT-based integrated approach

Psychoeducation—explain biopsychosocial model of anxiety/alcohol disorders

• Basic epidemiology

• Negative interactions between the two

• Introduce role of cognitions, thoughts, beliefs and expectations

• Teach diaphragmatic breathing to reduce hyperventilation


Cognitive restructuring—(req.CBT skills)

• Thinking patterns that contribute to initiating and maintaining anxiety and panic

• Recognized and restructure thinking that promotes alcohol use to cope w anxiety


Cue exposure—therapist guided exposure to fear provoking situations and sensations to decouple from anxiety and catastrophe

• Helps with reality testing

• Practice for anxiety management skills

• Enhance self-efficacy


• Exposures (imaginal and in vivo) expanded to include alcohol–relevant cues assoc. with anxiety states to decouple self-medication and practice other coping skills

CONCLUSION: Effects of Integrated CBT TX for comorbid panic and alcohol disorders was more effective for patients with the strongest for patients with strongest expectations that alcohol helps control their anxiety

Talking to Patients about Medications

• Make an inquiry every few sessions

• Are their Psych meds. Helpful? How?

• How many doses or how often do you miss?

• Acknowledge that taking pills everyday is a hassle and everybody misses sometimes

• Did they feel or act different? Or use?

• Explore connections of MH, meds, use

• Forget? Or choose not to take it.

Medication AdherenceComorbid SUD a Risk Factor for Non-adherence

• May have conflicted feelings and attitudes about medication

• Meds may be sometimes discouraged or thought to be un-needed

• See it as a sign of weakness

• May stop meds during relapse

• May misused meds


• Problem solve strategies to not forget– Use a pill box, help set it up– Keep it where it cannot be missed or avoided– Link med taking with some daily activity– Use an alarm clock set for the time to take– Ask someone to help them take meds


• Some patients may choose not to take meds– They have a right to make that choice– Owe it to themselves to make sure their important

health decision is well thought out– Explore-- “I just don’t like pills (or meds)”. – Elicit a reason—never needed it, cured now, don’t

believe in it, means I’m crazy, side effects, afraid, shame, cost, interpersonal, want to be in control, do it on my own, can’t use

– Motivational Interviewing

Psychotherapy for Patients with Co-occurring Disorders

“Skeptical Attunement:

Modifying Psychodynamic Technique for Substance Abuse Treatment”

Karen Frieder, PhD

Roy Futterman, PhD

Susan Silverman, PhD

Psychotherapy for DDX “Skeptical Attunement”

Skeptical attunement is the use of healthy skepticism as a means of confronting the patient in a way that is experienced as empathic attunement, leading to more meaningful work.


• Psychodynamic technique can fill a gap in current addiction treatment by addressing the emotional discomfort and disconnection that underlies a great deal of substance use.

• Model of psychodynamic work that will help to focus on patients’ emotional lives, their specific substance abuse behaviors and will make explicit the connections

• Help patients gain control over their substance use as well as their emotional lives.


Historical Context

• Addiction a symptom of underlying psychopathology

• Standard analytic technique without directly addressing substance use

• Others felt Tx not appropriate until sober or that patients were unanalyzable


Historical Context

• AA felt psychology had little to offer

• 12 Step, TCs, Self help, abstinence

• May have been anti-psychiatric care

• Patients in denial, not ready, haven’t hit bottom


Recent advances in psychotherapy for addiction treatment

– Relapse Prevention– Harm Reduction– Motivational Interviewing


Relapse Prevention– Assumes relapse a natural and predictable

part of the recovery process– Discuss and learn from each relapse to

prevent future relapses– CBT Function analysis– Relapse is not random and patients can learn

the patterns


• Harm Reduction– Patients accepted into treatment with various

levels of substance use– Abstinence not a mandated goal or

prerequisite– Practitioner seeks to reduce the negative

impact of substance use on patients– Similar to psychiatric treatment in that patients

are treated in individualized manner


Motivational Interviewing– Stages of change, change is a process– Different interventions for different stages– Patients ambivalence about use is normal– Enhance discrepancy– Therapist role to increase client motivation

Join with clients to gain insight and understanding to gain more control


Self Medication Theory: Patients use drugs to self-medicate intolerable emotions– Undiagnosed, untreated psychiatric illness– Grief and trauma – Difficulty regulating emotions– Disconnected from and unaware of emotions– Poor interpersonal skills and relationships


Modified Psychodynamic Technique: Goal to increase awareness, make the unconscious conscious and connect emotional life to using behaviors– Clinician more active and symptom focused– Asking about use, risky situations, triggers– Use of psychoeducation– More transparent and genuine– Discuss countertransference and skepticism


Working with Defenses– Main defense is to use. Also denial,

displacement, dissociation, intellectualization– Keeping “on the run” physically, interpersonally– Defense against what?– relate defenses to thoughts and emotions

which lead to urges and relapse– Talking about it (to gain insight) will lead to

mastery


Talking about Cravings and Triggers– Client reluctance to disclose: illegal, cause

them trouble, secret, weakness, guilty, shame, other associated bad behaviors

– Therapist: non-judgmental and more active– Deny cravings– Mistake withdrawal for cravings and cravings

for withdrawal


Talking about Cravings and Triggers– Behavioral patterns to cravings—People

places and things– Stress and emotions (negative and positive)– Mindfulness to physical and emotional self– Connection to behavior—before and after– Craving itself is short lived– Working with dreams


Talking about Cravings and Triggers– Recognizing and labeling to stop a relapse– Sensitivity to transitions– Pleasures, meanings and role of use (further

insight into triggers, losses and needs)– Fulfillment of rituals and excitement– Sexuality and intimacy


Skeptical Attunement: Any break from the norm should be assumed by the clinician to be related to relapse—there may be numerous signs and symptoms– clinician may point out changes and predict a

relapse (if before the relapse)– ask pointed questions about what’s happening– reference observations or recent behavior


Skeptical Attunement:– Contrast current to more usual behavior– Matter of fact attitude, assumption of relapse– Straightforward but not accusatory– May make disclosure more easy (or patient can

refute it)– Clients experience this as attunement; don’t

want a clinician who is overly trusting and naïve– Not attacking, not ignoring, “tuned in”– May help with clinician countertransference


Countertransference• Anticipate being lied to, manipulated, misused(attenuated with skeptical attunement and directly

addressing behaviors and observations)• Ineffectual, suspicious punitive interrogator(awareness of need for and origins of secretiveness)

• Hurt, disappointed and angry with relapse(attenuated with harm reduction and relapse prev)• Need to be seen as street savey (reflect w truth)• “Are you in recovery?” (explore but answer)

Documents

Co-occurring Disorders The Mix of Meds and Therapy Illinois Department of Human Services Cross Divisional Training February 19, 2008 Seth Eisenberg MD