Dual Diagnosis Case Studies

1
Dual Diagnosis Case Studies

• Mark Holland PhD
• Consultant Nurse
• Manchester Mental Health Social Care Trust
• 14.3.12
• Leeds Dual Diagnosis Network

2
Introduction

• Background care cluster 16 (dual diagnosis of
  severe mental illness and substance misuse)
• Cluster 16 needs and treatment guide
• Case studies
• Dual diagnosis beyond psychotic cluster 16
• Discussion and Conclusion

3
Cluster 16

• Cluster Description
• This group has enduring, moderate to severe
  psychotic or affective symptoms with unstable,
  chaotic lifestyles and coexisting substance
  misuse. They may present a risk to self and
  others and engage poorly with services. Role
  functioning is often globally impaired
• Diagnoses
• F20 -29 (Schizophrenia , schizotypal
  delusional disorders)
• F30 31 (Bi-Polar Disorder)
• F32.3 (Severe depressive episode with psychotic
  symptoms)
• Plus/with
• F10 19 (Mental behavioural disorders due to
• psychoactive substance use)
• Risk
• Overdose (intentional/accidental)
• Entry into CJS
• Harm to self
• Harm to others/From others
• Course
• Long term 3 yrs

4
C 16 Expected Needs

• Medication management/pharmacology
• Health education/harm minimization
• Engagement
• Motivational interviewing
• Social inclusion

5
C 16 Partnership working

• Substance misuse services (all sectors)
• CJS (probation/prisons/police)
• Housing
• Employment

6
Core Elements of Care

• Direct
• Engagement, Motivational interviewing techniques,
  CBT techniques, Harm minimisation/health
  promotion, Assertive Outreach Approach,
  Medication management, Assistance to increase
  social functioning, Relapse prevention
  strategies,
• As appropriate, advise/signpost/access self-help
  (e.g. groups), self-monitoring (e.g. triggers,
  early warning signs),
• Indirect
• Supportive empathic relationships, provide hope

7
C16 Pathway Needs

• CRISIS MANAGEMENT
• Management of intoxication
• Mental health relapse
• CARE COORDINATION 
• Should be under mental health service CPA
• Care coordination by someone experienced (level
  3 capability framework)
• Drug/alcohol relapse
• MONITORING OF PHYSICAL AND MENTAL HEALTH
• This should be the same as the other psychotic
  clusters with minimum of neuroleptic therapy
  NICE guide and attendance to BBV treatments and
  advice
• DETOX REHAB
• Access to detox (complex cases capability)
• Admission to appropriate complex needs
  rehabilitation

8
C16 QUALITY AND OUTCOMES GOALS

• Maximise quality of life and physical health
• Maintain appropriate contact (SBNT)
• Symptom management
• Prevent general worsening of condition
• Reduce risks (including Safeguarding)
• Support recovery hopes (both domains)
• Relapse prevention (both domains)
• Preventing complications associated with illness
  and medication as relevant (harm reduction and
  health promotion/ illness prevention)

9
Case Presentation 1 Christian

• General implications and exercise / discussion

10
Demographic

• 24 year old male Caucasian
• Lives between parents and girlfriends
• Has a 2 year old child
• Has a 14 year old brother
• Unemployed for 18 months, prior to onset of
  psychosis held various blue collar jobs
• Prison age 20 (violent offence in organised
  crime, served 3 years)

11
Past History 15-23

• Moderate alcohol
• Cannabis age 15 to present
• Initially symptom free
• Cocaine age 17 intermittent, no use for past 6
  months
• Noted by family to be intense in manner and hold
  emphatic beliefs about Free Masons and Illuminati
  
• Heavier cocaine use late teens
• Became involved in crime
• No IV use, no BBVs despite long term shared
  insufflation
• Abstained whilst in prison
• No treatment in prison, no reported
  symptomatology
• On release drinking increased
• Family raised concerns with GP about growing
  preoccupation with Illuminati and expression of
  related paranoid ideas, grandiose flavour

12
Past History 22/23

• Concerns
• Putting out cigarettes on forearms
• Isolating himself
• Striking his girlfriend
• Shouting at family (HEE reaction / household)
• Increased alcohol use
• Little cocaine or cannabis use
• Referred to CRHT, poor engagement both parties
  but calmer
• Referred to dual diagnosis service (DDS)

13
DDS Presentation

• Type I Diabetes
• No residual self harm damage or acts
• FTD, True auditory hallucinations, paranoid
  delusions with grandiose overtones,
  derealisation, depersonalisation, with ?Capgras
  syndrome
• Generalised anxiety both motor and autonomic
• Variable mood (prominent paranoia low mood
  versus prominent grandiosity high mood)
• Verbal expressions of anger towards family and
  girlfriend (HEE environment)
• Isolating himself
• Alcohol used to avoid/reduce anger and alleviate
  anxiety
• Anxiety correlates to delusional beliefs (even
  when grandiose)
• Disturbed / reversed sleep pattern
• Increasing alcohol misuse (relief drinking noted)
  and complications
• Fluctuating rapport from guarded and suspicious
  to engaging (desperate for help)

14
Provisional Diagnosis and Management

• Paranoid Schizophrenia / alcohol induced
  psychotic disorder with hallucinations and
  delusions
• Alcohol harmful use / dependence syndrome
• Neuroleptic Therapy
• Vitamin Therapy
• Motivational Interviewing
• Alcohol education and information
• Alcohol reduction / detox (community/ inpt)
• CMHT referral
• Alcohol Service referral?

15
Exercise

• In groups or pairs please list the possible
  additional issues
• E.g. Safeguarding, risk to staff, other services
  for cannabis, cocaine and other drugs, engagement
  issues, individual / family CBT etc
• List issues that have emerged in your practice
  with similar patients
• List services you have referred to or know of
  that may help Christian

16
Case Presentation 2 Kelly

• Motivational interviewing / Cognitive behavioural
  approach for
• distress, symptoms, motivation and coping

17
Overview

• 29 year old woman
• 2nd generation African Caribbean
• Lives alone in well kept flat
• 2 friends, one of whom visits 5 times a week
• Pet cat
• Limited contact with adoptive parents or siblings
  (all white British) for past 6 or 7 years
• Split from them was acrimonious (elements of
  illness associated)
• Diagnosed paranoid schizophrenia 6 years ago
• Previous schizotypal personality disorder
  diagnosed (PD label has stuck)
• Receives fortnightly risperidone consta 37.5mg
• On 3rd antidepressant
• Smokes skunkweed daily
• Crack cocaine and heroin smoked as treat
  fortnightly
• Hep C (prior IV use)

18
Mental health distress

• Paranoid feelings constant and pre curser to
• Paranoid ideation conviction level increases
  rapidly when outside among strangers and friends
  alike
• General anxiety psychomotor and autonomic
• Social anxiety / phobia
• Marked depression
• Anger specific to adoptive parents or at times
  of paranoid ideas of reference
• Feelings of rage free floating (and sometimes
  attached to adoptive family)

19
Paranoid ideation

• No consistent delusional belief elicited
• Feels under constant surveillance but guarded
  when describing / cannot elaborate (most days,
  throughout the day)
• Manageable when smoking cannabis and in her flat
• Ideas of reference from variety of sources when
  out
• Not specific to same individuals or groups
• History of violent response (stabbed a male
  stranger who voices said had raped her)
• Accompanied by true auditory hallucinations
• Paranoid ideation conviction rating 80-90

20
Hallucinations

• Does not recognise voices
• 2nd and 3rd person
• Derogatory, volume and intrusiveness varies
• Command
• in revengeful mode (rape victim)
• Harm self
• Occur on majority of days
• Coping
• Cannabis and isolation can cope
• Cannabis and going out sometimes cope
• No cannabis and out cannot cope
• Mood relieved by crack cocaine and heroin
• Voices conviction rating 90

21
Brief analysis of substance misuse

• PROS
• Feels chilled - relaxant effect (short lived)
• Boosts confidence
• Reduces feelings of rage and anger
• Enhances music
• Something to do
• Relieves low mood

• CONS
• Costly gt1 ounce cannabis a week (100) much as
  can afford of crack and heroin
• Conflicts with personal image of self reliance
  and physical fitness (previously fitness
  instructor)
• Feels dependent on it
• Artificially relieves anxieties
• Artificially creates euphoria
• Reduces sleep quality

22
Focus on one PRO - Chilled

• Voices less intrusive and voluble
• Anxiety (autonomic) diminishes
• Headaches, physical tension remains quite marked
• Paranoid ideation - unchanged in conviction
  frequency, less intrusive however
• Feelings of rage and anger about family less
  dominant
• Objective emphasise the self medication aspect
  that then reappears in a con

23
Focus on one CON artificially relieves
anxiety and improves mood

• Demonstrates insight of this maladaptive coping
  strategy (i.e. Short lived)
• there must be a way I can cope, without drugs,
  like other people do led to I used to manage
  OK
• Connects artificial psychoactive effect to her
  personal image belief of health and self reliance
• I feel less depressed when Im stoned but its
  wrong to rely on it.and that thought makes me
  feel lowespecially when Im no longer stoned
• Both statements demonstrate motivation to change

24
Motivation

• Necessary prior to cognitive behavioural work
• Shared goals and agenda
• Building motivation through motivational
  interviewing
• Strategies such as decisional balance matrix
  (pros cons)
• Principles of empathy, rolling with resistance,
  developing discrepancies, supporting
  self-efficacy
• Preparation for cognitive work can start at
  Contemplative stage of motivation

25
MI Preparation
established change
action
maintenance
preparation
contemplation
relapse
pre-contemplation
26
Decisional Balance Sheet
Not Change
Change
Good things
Not so Good
27
Importance and confidence
10
Readiness to change
Importance
0
10
Confidence
28
Preparation - Cognitive Model
Affect
View of past
Self-view
Cognitions
Behaviour
View of immediate life situation
View of future
29
Beliefs that predispose to change

• My current behaviour is bad for me (importance)
• I would be better off if I changed (importance)
• If I try to change I can be successful
  (confidence)
• This is a good time to do it (readiness)

30
Coming up with a Relapse Cycle or case
formulation
Beliefs (cannabis is good for me, need it to get
going, relieve tension/ anger, craving)
Trigger/High Risk Situation (out, paranoid
feelings anxiety low mood)
Auto Thoughts (What the hell! My life has turned
out bad)
Susceptibility to Triggers
Cravings / positive anticipation (physical and
psychological anticipated positive effect)
Sequalae (dissonance- feel bad / weakened
resolve relief short-lived)
Permissive thoughts (I deserve not to suffer this
tension, its not my fault)
Use / lapse / relapse (relief obtained)
Urge / Focus on Action (Score, roll joint -
relief begins)
31
Beliefs about substances that contribute to
cravings and urges
BELIEF PROCESS REPLACEMENT BELIEFS MAINTAINING STRATEGIES AFFIRMED REPLACEMENT BELIEFS
Anticipatory Expectations(relief- orientated) Permissive Catastrophic Assess, examine and test out belief (Socratic questioning, guided discovery) Not as good as expected Temporary relief only I used to do good satisfying things so I could do them again Its not my fault but I can do something else It can improve, this is a lapse not a relapse Cons flashcard Success flashcard Activity schedule Supporters / sponsors Imagery techniques I can get relief elsewhere / other ways I can do things OK I dont need it. Document and reference (flash card, anchor memories)
32
Relapse Cycle Opportunities for Intervention
Beliefs (good/bad for me, need a joint to get
going, relieve tension/ anger, craving)
Trigger/High Risk Situation (out, paranoid
feelings anxiety low mood)
Auto Thoughts (What the hell! My life has turned
out bad)
Susceptibility to Triggers
Cravings (physical and psychological
anticipated positive effect)
Red Cognitive Green - behavioural
Sequalae/ catastrophic (dissonance- eel bad /
weakened resolve, its getting worse)
Permissive thoughts (I deserve not to suffer this
tension, its not my fault)
Use / lapse / relapse (relief obtained)
Urge / Focus on Action (Score, roll joint -
relief begins)
33
Considering and selecting symptoms
34
Imagery techniques

• STOP (spoken volubly) and MINDS EYE visual
  imagery of stop sign, police officer, relative,
  sponsor
• IMAGE REPLACEMENT by empty wallet, hangover,
  physical injury, poor health, victim

35
Exercise (optional)

• Groups of 4-6 people
• Identify an existing client
• Or
• Create your groups own client
• Create a Relapse Cycle
• Highlight potential intervention opportunities
  within the relapse cycle Cognitive / behavioural
  / social / pharmacological
• Make a few notes for a brief feedback (if weve
  time!)

36
A FRAMES

• Assessment (thorough but not at expense of
  engagement)
• Feedback (accurate and specific to assessment)
• Responsibility (clients but may need graduating)
• Advice (accurate, evidenced neutral)
• Menu (of options)
• Empathy (avoid confrontation and resistance)
• Self efficacy

37
Conclusion

• Initial Focus on Engagement
• Thorough Assessment
• Symptom selection
• Intervention choice
• Motivational Interviewing Preparation
  Cognitive-Behavioural Techniques - Action
• Timing, perseverance and optimism

38
Did it work?
39
There is an alternative!
Russians thrash drug takers to stop addiction
On the first day we beat them with belts
until their buttocks turn blue. Every week we
have to buy a new belt because they go too soft,
but we have been impressed with the quality of
Gucci belts. Drug addicts are animals who have
lost all sense of values. This way, the next time
they think about getting a fix they remember the
pain of thethrashing rather than the rush of the
drugs. It's very effective. You cannot solve
this with mild manners - you need tough measures
City Without Drugs - Igor Varov Reported
by Drugscope
40
Dual diagnosis beyond c 16

• HONOS substance misuse subscale rating is
  conventionally substance treatment orientated
• SMI SM often need designating to 16 by care
  cluster rater
• No care cluster for non-psychotic DD (as yet)

41
Honos Substance Misuse Subscale

• Item Scoring
• 0 None No problem of this kind during the
  period rated.
• 1 Minor problem Some over indulgence, but
  within social norm.
• 2 Mild problem Loss of control of drinking or
  drug taking, but not seriously addicted.
• 3 Moderate problem Marked cravings or
  dependence on alcohol or drugs with frequent loss
  of control risk taking under the influence.
• 4 Severe problems Incapacitated by alcohol/drug
  problems.

42
End

• Any comments
• Thank you
• mark.holland_at_mhsc.nhs.uk