Transcript Chemical Dependency

Chemical Dependency
ARTSS Internship
June 7, 2011
Behavior Disorders
• Behavior disorders are disorders in which
the individual persistently engages in a
dysfunctional and problematic behavior and
does not stop.
• Behavior disorders are characterized by
their chronicity and high relapse rate.
• People with behavior disorders are not
normal people with problems; they are
problem people who appear normal.
Behavior Disorders
• Addictive Behaviors
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Alcoholism
Drug dependence
Smoking
Pathological Gambling
Sexual – pedophilia, exhibitionism, voyeurism
• Antisocial Behaviors
– Antisocial Personality
Addictive Behaviors
• Addictive behaviors in general
– Addictive behaviors may be viewed as a
complex progressive behavioral pattern with
biological, psychological, sociological, and
behavioral components
– What sets it apart from other behavioral
patterns is:
• Pathological involvement with the behavior
• Subjective compulsion to continue the behavior
Addictive Behaviors
• Reduced control over the behavior
• Object is to experience physical, emotional or
environmental elements of involvement in the
behavior
• Behavior continues despite its negative
consequences
• Behavior continues despite more gratifying sources
of reinforcement
Addictive Behaviors
• Dependence is experienced as a subjective distress
when this behavior is not carried out
• Tolerance is shown by a need to escalate the
behavior to achieve prior levels of reinforcement
• Urges are experienced as a strong desire for the
behavior
• Cravings are experienced as a strong desire for the
positive effects of the behavior
• Power of the addiction is shown by its rapid
reinstatement after cessation
Addictive Behaviors
– Common features of addictive behaviors
• Potent means of rapid mood change and sensation
because of physiological effects and learned
expectations
• Improvidence - short-term pleasure vs. long-term
negative consequences (one night with Venus, ten
years with Mercury)
• Psychological states, arousal levels, stress, pain and
negative moods be come associated with and
influence the likelihood of the behavior
Addictive Behaviors
• Classical and operant conditioning are important
parts of the addictive process
• Paradox of control - a behavior over which the
individual has diminished control is used as an
attempt to cope or exert more control
• High relapse rate
• Alternative behaviors often trigger return to the
target behavior
Addictive Behaviors
• Alternative behaviors often have a potential for
developing into an addictive behavior
• The stages of spontaneous remission are similar
across behavior
Addictive Behaviors
• Diagnostic Characteristics of Substance
Dependence
– Loss of control
– Physiological symptoms
• Tolerance
• Withdrawal
– Life problems
• Health (physical and mental)
• Legal
• Employment
Addictive Behaviors
• Social relationships
– Feeling dependent on the substance
• Urges to use the substance and cravings for its
positive effects
• Inability to function without the substance
• Studying substance abuse by studying the
substance is like studying holy water by
analyzing the water
Addictive Behaviors
• Evaluation
– History
• Onset, remissions, relapses, treatment, intoxication
symptoms, withdrawal symptoms, life problems
• Other sources of information - significant others,
other professionals, old records
– Lab tests
• Must make accurate diagnoses
– Real comorbidity vs. psychiatric symptoms due
to the substance use (MICAA vs. CAMI)
Dual Diagnosis
• Terminology
– The term dual diagnosis is ambiguous and in
1986 the New York State Commission on
Quality of Care for the Mentally Disabled
introduced the terms:
Dual Diagnosis
• What is dual diagnosis?
• This term refers to patients who have serious
DSM - IV Axis I psychiatric disorders and
chemical dependency
• Prevalences of substance use disorders in:
– Schizophrenia - 50%
– Bipolar AD - 60%
– PTSD - 60% to 80%
• Mentally ill chemical abusers and addicted (MICAA)
• Chemical abusing mentally ill (CAMI)
Dual Diagnosis
• MICAA - individuals with severe and
persistent mental illness accompanied by
chemical abuse or dependency
– The mental illness is independent of the
substance abuse and would exist without it
– The mental illness is a DSM - IV Axis I
disorder (schizophrenia, schizoaffective,
bipolar, severe chronic depression)
Dual Diagnosis
– MICAA patients usually require medication to
control their psychiatric illness and relapse
without it
– Substance abuse may exacerbate existing
psychiatric symptoms but symptoms persist
beyond withdrawal of the substance
– MICAA patients frequently display residual
effects of their psychiatric disorders (social
isolation, flat affect, lack of initiative, cognitive
impairment)
Dual Diagnosis
• CAMI - individuals with severe chemical
dependence with symptoms of mental
illness but who are not persistently mentally
ill
– CAMI patients have severe substance
dependence
– CAMI patients usually require treatment in
programs
– CAMI patients often have coexistent Axis II
– disorders
Dual Diagnosis
– CAMI patients appear in the mental health
system due to the “toxic” effects of the
substance that resemble the acute symptoms of
a psychiatric disorder (psychosis, suicidal
ideation). The acute symptoms are always
precipitated by the substance abuse.
– CAMI patients’ acute psychiatric symptoms
remit with detoxification and abstinence from
the substance - usually in weeks but it may take
months
Dual Diagnosis
– CAMI patients do not exhibit the residual
effects of a major mental illness when the
substance abuse is in remission
Addictive Behaviors
• Planning Treatment
• Alcohol withdrawal
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Tremors
Alcoholic hallucinosis
Seizures
Delirium tremens
Alcohol Behaviors
• Comorbidity
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Depression
Drug abuse/dependence
Post traumatic stress disorder
Schizophrenia
Bipolar affective disorder
Alcohol Behaviors
• Treatment
– Continued out patient alcoholism treatment
– Continued out patient psychiatric treatment
• Psychosocial
– Marital/family issues
– Employment issues
– Housing issues
Relapse Prevention
• Primary focus of relapse prevention is the
maintenance of habit change (it is easy to
stop smoking; I’ve done it 1000 times)
– To prevent slips
– To prevent slips from turning into relapses
• Addictive behaviors are over learned habit
patterns that can be changed through self
monitoring and self management.
Relapse Prevention
• Three main areas of self control strategies
are:
– Acquiring coping skills instead of addiction
– Fostering new cognitions, attitudes,
attributions, and expectancies about the nature
of the addiction and of the ability to control
one’s life
– Developing a life style that includes positive
self care activity and non destructive
satisfaction
Relapse Prevention
• Three premises
– Addictive behaviors are controlled by the same
variables that control non addictive behaviors
– The factors that initiate a behavior often differ
from the factors that maintain it
– To change the way people behave, it is
imperative to change the way they think.
Relapse Prevention
• Cognitive concepts
– Expectancies
• Outcome
• Efficacy
– Attributions
• Inferred causality in the explanation of one’s own or
another’s behavior
Relapse Prevention
– Cognitive distortions
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Overgeneralization
Selective abstraction
Excessive responsibility
Generalizing over time
Relapse Prevention
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Self reference
Catastrophizing
Dichotomous thinking
Absolute willpower breakdown
Body over mind
Problem Analysis
triggers
thoughts
feelings
response
consequen
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Decision making
• Motivation
• Apparently irrelevant decisions
• Poor decisions
Decision Making
Cost
Drink
Don’t drink
Benefit
Relapse Prevention
• Reference
– Marlatt and Gordon, Relapse Prevention:
Maintenance Strategies in the Treatment of
Addictive Behaviors, Guilford Press, 1985
– Marlatt and Donovan, second edition, 2007
Motivational Interviewing
Motivation
• Motivation is the readiness for change
• The most common misconception is that
motivation is a fixed characteristic of the
client
• Motivation is not fixed and external factors
have a major influence on motivation
• Motivation is controlled by the interaction
of the client with those around him or her
Motivation
• Technique - designed to minimize the
client’s resistance to changing his or her
behavior
• To understand motivational interviewing
one must understand
– Cognitive dissonance
– Psychological reactance
Motivational Interviewing
• Purpose is to increase client motivation for
change
• Confrontational but not in the usual sense
– Intent is to bring client to a greater awareness
of his personal responsibility for the problem
– Underlying strategy is to create a dissonance
between the clients current behavior and his
personal goals
FRAMES
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Feedback of personal risk or impairment
Responsibility of the individual for change
Advice on how to change
Menu of change options
Empathy by the therapist
Self-efficacy support by the therapist
Increasing Client Motivation
• Remove barriers
• Decrease attractiveness of current behavior
• External contingencies - letter for work,
commitment
• Goal setting - help the client set a clear goal
for change
• Helping attitude - reflective listening
Motivational Principles
• Express empathy - reflective listening
• Develop discrepancy between where client
is and where he or she wants to be
• Avoid argumentation - this decreases client
defensiveness
• Roll with resistance - solutions are evoked
from the client and not imposed by the
therapist
Motivational Interviewing
• Reference
– Miller WR, Rollnick S, Motivational
Interviewing: Preparing for Change, 2nd
Edition, Guilford Press, 2002
Strategies for Remaining Sober
• Remember sobriety is your number one priority.
• Avoid risky people and places.
• Remember the problems that drinking caused you.
Do you want them back again?
• Go to meetings and self help groups.
• Stay in alcohol free environments.
• Avoid thinking about alcohol.
• Remember the benefits of being sober.
Just Do It
• You do not need to understand something to
make it work for you.
– I get to the airport on time, get on the plane,
and get off when it lands. I do not need to know
aerodynamics to get to where I am going.
– The sun rises in the east and sets in the west.
Your child does not need to know that this is
due to the earth’s rotation to get home before
dark.