Co-occurring Alcohol and Other Drug and Mental Health Conditions in Alcohol and other Drug Treatment Settings

1
Co-occurring Alcohol and Other Drug and Mental
Health Conditions in Alcohol and other Drug
Treatment Settings

• Session 2
• Classificationof Mental Disorders

2
Comorbidity Guidelines

• Refer to
• Chapter 5

3
Classification - Key Points

• Disorders represent particular combinations of
  signs and symptoms grouped together to form
  criteria as per DSM-IV-TR
• Certain number of criteria need to be met within
  a certain time frame for a person to be diagnosed
  as having a disorder
• Not all AOD workers are able to formally diagnose
  the presence or absence of mental health disorders

4
Classification Key Points (2)

• Diagnoses of mental health disorders should only
  be made by suitably qualified and trained health
  professionals
• Useful for all AOD workers to be aware of
  characteristics of disorders so are able to
  describe and elicit mental health symptoms when
  undertaking screening and assessment, and to
  inform treatment planning

5
Symptoms without Diagnosis

• Classified as mental health disorder must meet
  diagnostic criteria
• However, large number in AOD services who display
  symptoms but do not meet criteria
• (Eg anxiety but without an anxiety disorder)
• Can still impact significantly on functioning and
  treatment outcomes

6
Categories of MH Disorders in Comorbidity
Guidelines

• Mood disorders
• Anxiety disorders
• Personality disorders
• Psychotic disorders
• Substance-induced disorders

7
Mood Disorders

• Major depressive episodes
• Manic episodes
• Mixed episodes
• Hypomanic episodes.

Major depressive episode
Manic episode
Hypomanic episode
Normal mood
Depressed mood
Elevated mood
8
Major Depressive Episode

• Some of following symptoms experienced nearly
  every day for at least 2 weeks
• Depressed mood or loss of interest or enjoyment
  in activities
• Reduced interest or pleasure in almost all
  activities
• Change in weight or appetite
• Difficulty concentrating or sleeping (i.e.,
  sleeping too much or too little)

9
Major Depressive Episode (2)

• Restlessness and agitation
• Slowing down of activity
• Fatigue or reduced energy levels
• Feelings of worthlessness or excessive/inappropria
  te guilt
• Recurrent thoughts of death, suicidal thoughts,
  attempts or plans

10
Manic Episode

• Person experiences abnormally elevated,
  expansive, or irritable mood for at least 1 week
  characterised by
• Inflated self-esteem
• Decreased need for sleep
• Increased talkativeness or racing thoughts
• Distractibility
• Agitation or increase in goal directed activity
  (e.g., at work or socially)
• Excessive involvement in pleasurable activities
  that have a high potential for negative
  consequences.

11
Hypomanic and Mixed Episodes

• Hypomanic same as manic episode but is less
  severe
• May only last 4 days and does not require the
  episode to be severe enough to cause impairment
  in social or occupational functioning
• In mixed episode, person experiences both a manic
  episode and major depressive episode for at least
  1 week

12
Anxiety Disorders

• Many people feel anxious because they have reason
  to eg trouble with law, homelessness
• Many in AOD treatment will experience anxiety as
  consequence of intoxication, withdrawal, or
  living without using AOD
• Usually reduces over time with period of
  abstinence
• Problematic when persistent, or so frequent and
  intense that prevents person from living his/her
  life in the way that he/she would like

13
Panic Attack

• Sweating
• Shaking
• Shortness of breath
• Feeling of choking
• Light headedness
• Heart palpitations, chest pain or tightness
• Numbness or tingling sensations

• Chills or hot flushes
• Nausea and/or vomiting
• Fear of losing control, going crazy or dying
• Feelings of unreality or being detached from
  oneself

14
Types of Anxiety Disorders

• Generalised anxiety disorder (GAD)
• Obsessive compulsive disorder (OCD)
• Panic disorder
• Agoraphobia
• Social phobia
• Specific phobia
• Post traumatic stress disorder (PTSD)
• Acute stress disorder.

15
PTSD

• Can develop after traumatic event
• May experience some of following
• Intrusions re-experiencing event as nightmares,
  or flashbacks
• Avoidance avoiding thoughts, feelings, people,
  places or activities that remind him/her of the
  event,
• Hyperarousal increased startle response,
  irritability or anger, difficulty sleeping and
  concentrating

16
Personality Disorders

• Enduring destructive patterns of thinking,
  feeling, behaving, and relating to other people
  across wide range of social and personal
  situations
• Maladaptive traits are stable and long lasting
• Tend to develop in adolescence or early adulthood
  and are generally lifelong
• Most common in AOD context ASPD and BPD

17
AOD and Personality Disorders

• AOD use disorders may cause fluctuating symptoms
  that mimic symptoms of personality disorders
• Eg impulsivity, aggressiveness,
  self-destructiveness, relationship problems, work
  dysfunction, engaging in illegal activity,
  dysregulated emotions and behaviour
• Can be difficult to determine whether a person
  has a personality disorder

18
Antisocial Personality Disorder

• Failure to conform to social norms with respect
  to lawful behaviour
• Disregard for the wishes, rights and feelings of
  others
• Deceptive and manipulative in order to gain
  personal profit or pleasure may repeatedly lie
  or con others
• Reckless disregard for own or others safety

19
Antisocial Personality Disorder (2)

• Impulsive behaviour decisions made on spur of
  the moment, without forethought, and without
  consideration of the consequences for self or
  others
• May lead to sudden change of jobs, residences or
  relationships
• Irritability and aggression repeated involvement
  in physical fights or assaults
• Consistent and extreme irresponsibility

20
Borderline Personality Disorder

• Persistent patterns of instability in
  relationships, mood, and self-image
• Marked impulsivity, particularly in relation to
  behaviours that are self-damaging
• Extreme efforts to avoid rejection or abandonment
  
• Pattern of unstable and intense relationships
• Unstable self-image or sense of self

21
Borderline Personality Disorder (2)

• Impulsivity
• Recurrent suicidal behaviour, threats or
  self-mutilating behaviour
• Unstable mood
• Chronic feelings of emptiness
• Inappropriate, intense anger
• Stress-related paranoid thoughts or severe
  dissociative symptoms

22
Psychotic Disorders

• Loss of touch with reality
• Feelings, thoughts and perceptions severely
  altered
• Delusions and Hallucinations
• May be due to intoxication or withdrawal from
  substances
• If the person experiences psychotic episodes when
  not intoxicated or withdrawing, possible they may
  have one of the disorders described

23
Delusions

• Fixed, false beliefs not consistent with cultural
  context
• Involve a misinterpretation of perceptions or
  experiences
• Eg feel that someone is out to get them, they
  have special powers, or passages from newspaper
  have special meaning for them

24
Hallucinations

• Disturbance of sensory perceptions
• Auditory (hearing voices or sounds)
• Visual (seeing things not present)
• Olfactory (smelling things not present)
• Tactile (feeling or sensing something)
• Gustatory (taste)

25
Other Symptoms of Psychosis

• Disorganised speech
• Grossly disorganised behaviour
• Catatonic behaviour (eg decreased reactivity)
• Affect flattening (reduced range of emotional
  expressiveness)
• Alogia (restricted thought and speech)
• Avolition (reduced involvement with activities)

26
Schizophrenia

• Most common and disabling of psychotic disorders
• Affects ability to think, feel and act
• To be diagnosed symptoms must have been
  continuing for a period of at least 6 months
• Symptoms are grouped within 2 types
• Positive symptoms
• Negative symptoms

27
Positive Symptoms of Schizophrenia

• (Not as in pleasurable!)
• Presence of excess or distortion of normal
  functioning and include hallucinations,
  delusions, disorganised speech, grossly
  disorganised behaviour and catatonia

28
Negative Symptoms of Schizophrenia

• Absence of normal functioning including affective
  flattening, avolition, alogia
• Can cause significant impairment in a persons
  functioning
• Classification of types of schizophrenia
  depending upon the predominance of symptoms
  displayed (paranoid, disorganised, catatonic,
  undifferentiated, residual type)

29
Other Psychotic Disorders

• Schizophreniform disorder equivalent to
  schizophrenia except its duration limited to less
  than 6 months
• Schizoaffective disorder symptoms of
  schizophrenia alongside major depressive, manic
  or mixed episode
• 2 types i) bipolar type (if manic or mixed) ii)
  depressive type (if major depressive)

30
Substance-Induced Disorders

• Occur as direct consequence of AOD intoxication
  or withdrawal
• Diagnosis requires symptoms only present
  following intoxication or withdrawal
• If symptoms in absence of intoxication or
  withdrawal, possible they have independent mental
  health disorder
• Symptoms tend to reduce over time with period of
  abstinence

31
Examples of Substance Induced Disorders

• Alcohol use/withdrawal - symptoms of depression
  or anxiety
• Manic symptoms induced by intoxication with
  stimulants, steroids, hallucinogens
• Psychotic symptoms induced by withdrawal from
  alcohol, intoxication with amphetamines, cocaine,
  cannabis, LSD or PCP
• Other disorders - substance-induced delirium,
  amnestic disorder, dementia, sexual dysfunction,
  sleep disorder

32
Substance-Induced Psychosis

• Difficult to distinguish substance-induced
  psychosis from other psychotic disorders
• Substance-induced psychosis - symptoms appear
  quickly and last relatively short time, from
  hours to days until the effects of drug wear off
• Psychosis can persist for days, weeks, months or
  longer
• Possible individuals already at risk for
  developing psychotic disorder triggered by
  substance use

33
Substance-Induced Psychosis (2)

• Visual hallucinations more common in substance
  withdrawal and intoxication
• Stimulant intoxication more commonly associated
  with tactile hallucinations, person experiences
  physical sensation interpret as having bugs under
  skin ("ice bugs" or "cocaine bugs)
• Tactile hallucinations can occur in alcohol
  withdrawal auditory and visual hallucinations
  are more common

34
Substance-Induced Psychosis (3)

• Stimulant psychosis sometimes more agitated,
  energetic, more difficult to calm with sedating
  or psychiatric medication compared to non-drug
  induced psychosis
• Difference with schizophrenia - lack of negative
  and cognitive symptoms with return to normal
  inter-episode functioning during periods of
  abstinence

35
Delirium

• Disturbance of consciousness and cognition that
  represents significant change from previous level
  of functioning
• Reduced awareness of surroundings, difficulty
  concentrating, may be difficult to engage him/her
  in conversation
• Changes in cognition include short-term memory
  impairment, disorientation (in regards to time or
  place), language disturbance (eg difficulty
  finding words, naming objects, writing)

36
In sum

• Not all clients with symptoms of mental illness
  will meet diagnostic criteria
• Diagnostic labels can be very useful but should
  not be limiting!
• Diagnosis needs to be undertaken by trained
  professionals however important to be aware of
  symptoms and to be able to communicate with other
  professionals, clients and families/carers