Transcript Dual Diagnosis

Dual Diagnosis
Dr Nikki Wood
Principal Clinical Psychologist
Forensic Dual Diagnosis Service
John Howard Centre
Definitions
• The term “dual diagnosis” is generally applied to
people who have two or more diagnosed
disorders
• Combined mental health and substance use
problems
• More than “dual problems”- likely to have
complex health and social needs
• Wide range of people with varying degrees of
need (c.f. individualised treatment)
Severity of problematic HIGH
Substance Misuse
e.g. a dependent drinker who experiences
increasing anxiety
e.g. an individual with schizophrenia who
misuses cannabis
Severity of Mental Illness
LOW
e.g. a recreational misuser of ‘dance
drugs’ who has begun to struggle with low
mood after weekend use
HIGH
e.g. an individual with bipolar disorder
whose occasional binge drinking and
experimental misuse of other substances
destabilises their mental health
LOW
“Mainstreaming”
DH (2002) Good Practice Guide:
• Doesn’t advocate a separate specialist service for dual
diagnosis
• Mental health services should take primary responsibility
for those with serious mental health problems (like
schizophrenia) and substance use
• Substance use services should take primary
responsibility for those with primary substance problems
and common mental health problems (anxiety,
depression)
• However mental health and substance use services
should work together and support each other
Consequences in dual diagnosis
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Young, single, male, homeless
lower educational and employment attainment
higher rates of relapse
longer inpatient stays (twice as long - Menezes et al,
1996)
• non-adherence to medication
• higher rates of violence, suicide and self harm
• higher likelihood of involvement with the criminal justice
system,
(Drake and Meuser, 2000)
• Poor physical health - higher rates of HIV, Hep B and C,
and other substance use related physical problems
• Family problems
• Difficulties getting access to appropriate aftercare
• High overall service costs
• Higher overall risk of untoward incidents
(Drake and Meuser, 2000)
Nutt, King &Phillips, (2010) Drug harms in the UK: a
multicriterion analysis, Lancet, online 1st November 2010
Reasons For Drug Use
(in people with mental health problems)
• Hedonism, escape and fun
• Self medication
• Cravings
• Medicate medication side-effects.
• Peer acceptance/ social factors.
• Boredom.
• Coping with stressful relationships/situations
Self-medication
• The use of substances to alleviate painful or uncomfortable
emotional or physical states.
• Positive and negative symptoms of psychosis (apathy, flattened
affect, slowed thoughts)
• Side-effects of medication (EPSE, akathisia, neuroleptic dysphoria)
• General distress as a result of having a chronic illness (boredom,
loneliness, distressing symptoms, labelling)
• Although this hypothesis is not fully supported by the research, and
could be considered a convenient medical model explanation
Bio-psycho-social model of
Psychosis
• Developing psychosis is a combination of biological,
psychological and social factors
• Biological factors include genes and a history of mental
illness in the family
• This would lead individuals to be more prone to
developing psychotic symptoms at times of stress
(stress-vulnerability model)
• Substance use is also likely to affect the brain chemicals
of vulnerable people
Zubin & Spring’s Model of the Interaction Between
Vulnerability & Stressful Events in Triggering an
Episode of Schizophrenia (1977)
Maximum
ill
Challenging
Events
Threshold
Well
Minimum
Low
High
Vulnerability
Psychological factors
• Anxiety and depression
• Stress
• Poor coping and social skills
• Difficult early childhood experiences
• Poor self esteem and sense of self
• Unusual perceptual experiences
• Perception of events as personal and traumatic
Social Factors
• Substance use
• Homelessness
• Financial worries and social deprivation
• Work/school problems/family conflict
• Difficult relationships with others
• Isolation –leads to poor reality testing
• Major life events
Drugs and mental health
Cannabis
• Known as skunk, weed, resin, ganja, grass,
blow, hash, spliff, sensi, sensimilla, smoke
• Was reclassified to Class B in January 2009
• Is usually smoked with tobacco rolled in a Rizla
paper.
• Main active ingredient is ∆THC
(tetrahydrocannabinol)
• Cannabis can cause anxiety, panic attacks,
paranoia and restlessness
Cannabis
• People with psychotic symptoms are more than twice as
likely to use cannabis as those without
• Why is this? The jury is still out but may be selfmedicating
• However research suggests that cannabis use,
especially the use of stronger forms of cannabis such as
skunk, can increase the likelihood of developing
schizophrenia in psychosis-prone individuals
• New research has found there is a particular marker
gene for a negative response
• Age of first use also a factor
Does cannabis cause sz?
• Does cannabis cause schizophrenia?
– Childhood use found to double chances of schizophrenia in later
life
– Andreasson et al 1987
• The higher the frequency of use prior to age 18 the more
likely to develop schizophrenia
– Arseneault et al 2002
• If using by 15 you are 4.7% more likely to develop
schizophrenia
• If using by 18 you are 10.3% more likely to develop
schizophrenia
• Semple et al (2005) in their meta-analysis found that early use of
cannabis was related to an increased risk of psychosis, and
vulnerable groups were those who had used cannabis at a very
early age, those who had already experienced psychotic symptoms
and those with a genetic risk for developing SZ.
• Vigella (2008) also found that frequency of use was also a factor
with daily cannabis use found in 66% of their early onset sample
• Cannabis potency recently confirmed to be a factor (Di Forti et al,
2009; n=280) with skunk increasing the risk of psychosis 6.8 times.
Length of use (more than 5 years) and frequency (daily) also
found to be factors.
• However Hickman (2009) found that you would need to stop 2,800
heavy male users or more than 5,000 heavy female users to prevent
a single case of schizophrenia
Cannabis
• Recent research has found that some chemicals in
cannabis may have antipsychotic and antianxiolytic
effects
- cannabidiol (CBD)
• which may explain why some people keep on using it
despite the THC sometimes making other symptoms
worse. e.g. paranoia
• Some evidence that there can be paranoia and agitation
on withdrawal – psychological dependence?
• Harm minimisation most helpful, smoke less, and smoke
less strong versions e.g. avoid skunk and sensimilla
So cannabis use can contribute to the development of
psychosis, especially the use of skunk at an early age
And ongoing and frequent use can make symptoms worse
or lead to a relapse
But also used to help with symptoms – paradox!
New research has found there is a particular gene that may
in the future mark out who is more vulnerable to
psychosis and who will have a negative effect from
cannabis
Alcohol
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Is a CNS depressant
At low doses has a disinhibiting effect
At higher doses leads to dysphoria/low mood
Depressive effects are transient
Strongly linked with violence and suicide
Is also a factor in personality disorder and
pathological jealousy
• Use common with axis 1 and axis 2 disorders
• May be used to manage hyperarousal or agitation
but also masks symptoms
• Also used to cope with physical pain
• Withdrawal could lead to increased arousal and exacerbation
of symptoms
• Used as a means of avoidance –cognitive and emotional
• May relieve feelings of isolation, loneliness, emptiness and
anxiety
• Prolonged excessive use can lead to brain and liver damage
and memory problems
• Also linked with heart disease and cancer.
• Withdrawal/hangover can lead to anxiety
• May be used to cope with anxiety, PTSD symptoms, sleep
problems, social phobia and depression
• Commonly used with other substances
Cocaine/crack
• Is a stimulant
• Coke, charlie, snow, freebase
• Crack is made by chemically altering cocaine powder to
form ‘rocks’
• Latest figures state the street cocaine is only around 4%
pure.
• Cocaine is usually snorted whereas crack is smoked in a
pipe
• Effects are more intense when smoked as crack as gets to
brain quicker – high lasts about 5 minutes
• After the first pipe, the euphoric effects decrease and the
withdrawal effects increase meaning people need to take
more and more
• General effects are: alert, energetic, confident, mentally
powerful, feel physically strong, increased heart rate,
dilated pupils.
• On intoxication, can lead to
– agitation, suspiciousness, paranoia, impaired
reality testing, impaired memory
• In withdrawal
– depression, suspiciousness, paranoia,
impaired reality testing, impaired memory
• When cocaine is used with alcohol, the body
creates a substance called cocaethylene, which is
toxic to both heart and liver and which remains in
the body for up to four or five days.
• Use can lead to depression and suicidality
• Formication – ‘cocaine bug’ – sensation of insects
crawling under your skin
• May also be used to augment hypomania, temporarily
relieve depression and counteract hyperactivity and
ADHD.
• Risk of violence and acquisitive offending either when
high or when on withdrawal and cravings in order to
purchase more
• Crack and cocaine may be taken in order to give
permission to offend, either by numbing affect/feelings of
empathy, or through increasing confidence and feelings
on invincibility
• Forensic patients frequently say they acted in ways
when they were high on crack which they would not do if
they were straight.
• Crack and cocaine use associated with unsafe sexual
behaviours
• Addiction to crack can lead to sex working (in both males
and females) and the associated risks of STD’s.
Heroin
• opiate based pain-killer/sedative
• Class A
• Known as smack, brown, scag, junk, H. Derived from the
opium poppy and medical name is Diamorphine.
• very addictive, both physically and psychologically
especially when injected, can also be smoked.
• withdrawal symptoms physically very unpleasant
• Withdrawal symptoms (onset within 6 hours, and peak at
36-48 hours, lasts up to 7 days) include:
Intense craving, restlessness, insomnia, pain in muscles and
joints, running nose and eyes, sweating, abdominal cramps,
vomiting, piloerection, dilated pupils, disturbance of temperature
control
• But can lead to anxiety and depression
• associated with personality disorders
• In London, heroin is approximately 40% pure
on the street. The rest can be anything such
as glucose, brick dust, lactose, baking
powder, gravy browning and basically
anything that resembles heroin.
• Is a pain killer/emotional numbing – PTSD
and abuse
• May attenuate feelings of rage or violence
• Can also however increase feelings of
confidence and invincibility.
Ecstasy/MDMA
• currently not clear about long term effects –
depression? Cognitive function - research is
still inconclusive
• may cause low mood in days following use ‘suicide Tuesday’
• is a hallucinogen so may be linked with
increase in symptoms
• disrupted sleep associated with use,
especially in clubbing culture
• In media, reports that can help those to
access memories of trauma and reduce
anxiety/distress levels
• So use could also be self-medicating for
PTSD symptoms
Crystal Meth
• Derivative of amphetamine
• Commonly used in non-EU countries but recently use
has started to increase in the UK
• Can be found in tablet, powder or crystal form
• Crystal form, known as crystal meths or ‘ice’ can be
smoked and is most potent and harmful
• Rush of 5-30 minutes depending on administration and
high last for 8-24 hours
• Causes increased arousal and motor activity,
disinhibition, diminished fatigue, sleep and appetite.
• Can lead to MA induced psychosis even after brief
period of use
• Long term use can also lead to brain damage
• Premorbid schizoid/schizotypal PD may predispose
MA users to psychosis and the greater the
vulnerability, the longer the psychosis will persist
• Use seems to be particularly linked to unsafe sexual
behaviour and transmission of STDs
• Paranoia and agitation especially linked to violence,
both from use and withdrawal
Other common drugs
• Speed/amphetamines (stimulant)
- disordered thinking, paranoia,
restlessness, poor sleep, hallucinations
- use can trigger psychosis in vulnerable
individuals and create psychotic like
symptoms when taken in large
amounts
- exacerbates positive symptoms
• LSD/Acid – can trigger psychosis in vulnerable
individuals
• Miaow miaow
• Khat
Principles of Integrated Treatment
Harm reduction
• Treat/investigate medical problems e.g. BBV, access to
food/vitamins, stable housing/finance, moderation goal,
substitution therapy.
• Time unlimited services
- to allow long-term change
• Motivation-based treatment – motivational interviewing
• Multiple psychotherapeutic modalities
- CBT based groups, 12 step programme, individual
therapy, faith based rehabilitation.
The Wheel of Change
Drug free support
group
Lapse
Interview
NA
Permanent
exit
Maintenance
Action
Stage 2
Groups
and
individual
therapy
BEGINS WITH
Relapse
Pre-contemplation
Contemplation
Preparation
Ward based
Stage 1
Groups