Transcript Dual Diagnosis: My Experience, Strength, and Hope

Dual Diagnosis:
My Experience,
Strength, and Hope
Chris Stewart, MD
“ Sometimes crazy
doesn’t go away
when you’re sober.”
Anonymous
”
Burns Brady
Grand Rounds, University of
Louisville Department of
Psychiatry 1997
“He discussed how an
addict was incorrectly
diagnosed with Narcissistic
Antisocial Sociopathic
borderline with psychotic
tendencies”
“Demonstrated that
impaired physician addicts
could be successfully
treated with a high success
rate utilizing 12 step
recovery and the
biopsychosocial model
when applied with sincerity
and compassion.”
“Drunker than Cooter
Brown”
“Drunker than Cooter
Brown”
 Archetype for southern alcoholism
 Where would it fit into the DSM-V?
 How does humor function in this legend?
Robert Frierson, MD
 Professor of Psychiatry,
UofL SOM
 Director of C/L
Psychiatry
 Program Director of
Psychosomatic
Fellowship
Causes of Delirium to
consider:
 Medications
 Benzodiazepines
 Infection/Metabolic
 UTI’s
 Withdrawal
 Alcohol
 Hypoxia
 COPD/CHF
 Malnutrition
 Thiamine deficiency
 Usually more than one
reason.
What is your Bias? Know your
history…..
Delirium and Psychosis
 This experience can be traumatic
 Having a mental illness is traumatic
 Having addiction can be traumatic
 Trauma is defined by the subjective experience of the
individual, and therefore has no defined
characteristics
 Ask your patients about their experience of their
symptoms when they have withdrawal delirium,
psychosis, mania, or other mental status changes
?Self Medication
Hypothesis?
 Khantzian (1982) observed that Heroin addicts were
using the drug to ‘soothe’ their aggression and rage.
 Addicts were not simply seeking pleasure
 Eventually he expanded his theory to how it applied to
most drugs of abuse that reduce anxiety
 Drug addicts were predisposed to use certain drugs to
help with affect regulation (ADHD/Cocaine, Social
Anxiety/Alcohol)
…The rest of the story
 This theory has been used by many to bypass
understanding addiction as a primary disease.
 Khantzian’s worked from a psychodynamic model
based on ideas from Kohut (1977) around self object
needs and the vulnerable self.
 Theory also has been used to ignore the effects of
PAWS, and substance induced ‘mental illness’
Biological/Managed Care
Revolution
 Inpatient Psychiatry model meets managed care
 Shorter duration of stays beginning in the early 90’s
 At the same time a similar change in long term residential
treatment for addiction or outright collapse
 Emergency Psychiatry Services at ULH
 Turf war over “dual diagnosis” patients between ULH and
JADAC
 ER didn’t want to manage alcohol intoxication
 “They don’t belong here”
The Healing Place
 “Is Bipolar disorder over
diagnosed among
substance abuse
disorders?” Bipolar
Disorders 2006. Stewart
and El-mallakh.
 Interviewed subjects
utilizing Structured
Clinical Interview
 Findings were
replicated
 45 citations
Examples of Dual Disorders:
MENTAL DISORDERS
 Schizophrenia
ADDICTION
DISORDERS
 Bi-polar
 Alcohol Abuse/Depen.
 Major Depression
 Cocaine/ Amphet
 Borderline Personality
 Post Traumatic Stress
 Social Phobia
 ADHD
 Opiates
 Marijuana
 Polysubstance combinations
 Prescription drugs
Post Traumatic Stress Disorder and Addiction:
DUAL DIAGNOSIS TREATMENT PROJECT AT THE
UNIVERSITY OF LOUISVILLE
 Integrating Cognitive Neuroscience
Research and Cognitive Behavioral
Treatment with Neurofeedback Therapy
in Drug Addiction Comorbid with
Posttraumatic Stress Disorder: A
Conceptual Review Tato M. Sokhadze,
PhD Christopher M. Stewart, MD Michael
Hollifield, MD Journal of Neurotherapy
2007
Dual Diagnosis Project cont’

Sokhadze, E., Stewart, C., Sokhadze, G., Hollifield, M., & Tasman, A.
(2009) Neurofeedback and motivational interviewing based biobehavioral treatment in cocaine addiction. Journal of. Neurotherapy,
13, 84-86

Sokhadze, E., Stewart, C., Sokhadze, G., Husk, M, & Tasman, A. (2009)
Effects of neurofeedback-based behavioral therapy on ERP measures
of executive functions in drug abuse. Journal of Neurotherapy, 13(4),
260-262.

Sokhadze, E., , Stewart, C., El-Baz, A., Ramaswamy, R., Hollifield, M., &
Tasman, A. (2009) Induced EEG gamma oscillations in response to
drug- and stress-related cues in cocaine addicts and patients with
dual diagnosis. Journal of Neurotherapy, 13(4), 270-271.

Sokhadze, E., Stewart, C., Hollifield, M., and Tasman, A. “Event
related potential study of executive dysfunctions in a speeded
reaction task in cocaine addiction. Journal of Neurotherapy, 2008,
v.12, N.4.

Sokhadze, E., Stewart, C., Hollifield, M., and Tasman, A. “Attentional
bias to drug related and stress related pictorial cues in cocaine
addiction co morbid with post-traumatic stress disorder.” Journal of
Neurotherapy, 2008, v 12, N.4.
Surgeon General’s Report
2016 on Alcohol and Substances
 20 million persons with addiction in the United States
 Most patients have never been asked/screened
about their drug/alcohol use.
 Co-occurring disorders are mentioned only briefly.
 Emphasis on the brain diseases aspect of addiction
and brain exposure to chronic drug use, “not a moral
issue”
 Represents a major milestone in the history of
addiction and addiction treatment.
 Strong scientific evidence for effectiveness of 12 step
recovery and the need for long term strategy.
Believe it or not,
 In my practice, on average, every two weeks I
interview a patient who is asking to see me about their
use of alcohol
 Recently a patient stated he had never had anyone
suggest to him that he stop
 Or – no one has asked them about whether their
drinking was a problem despite the fact that they
were complaining of depression/anxiety
 Also, often I hear, “no one ever asked me….: trauma,
addiction, past family history of addiction”
What’s my diagnosis Doc?
 How long have you been sober?
 IF not sober, has there been a considerable period of
time when you were?
 If not, then it will be difficult to answer this question
outside of the substance use, if not impossible
 Did either of your parents have a problem with
alcohol?
DSM-V Differential Diagnosis
Handbook
 “The process of DSM-5 differential diagnosis can be
broken down into six basic steps: 1) ruling out
Malingering and Factitious Disorder, 2) ruling out a
substance etiology, 3) ruling out an etiological
medical condition, 4) determining the specific primary
disorder(s), 5) differentiating Adjustment Disorder from
the residual Other Specified and Unspecified
conditions, and 6) establishing the boundary with no
mental disorder. “ DSM-V handbook of differential
diagnosis.
Likelihood of a Suicide
Attempt
Risk Factor
Increased Odds Of
Attempting Suicide
 Cocaine use
62 times more likely
 Major Depression
41 times more likely
 Alcohol use
8 times more likely
 Separation or Divorce
11 times more likely
NIMH/NIDA
ECA EVALUATION
The Four Quadrant Framework for
Co-Occurring Disorders
A four-quadrant
conceptual
framework to guide
systems integration
and resource
allocation in treating
individuals with cooccurring disorders
(NASMHPD,NASADAD,
1998; NY State; Ries,
1993; SAMHSA Report
to Congress, 2002)
High
severity
Less severe
mental disorder/
more severe
substance
abuse disorder
Less severe
mental disorder/
less severe
substance
abuse disorder
Low
severity
More severe
mental disorder/
more severe
substance
abuse disorder
More severe
mental disorder/
less severe
substance
abuse disorder
High
severity
Not intended to be
used to classify
individuals (SAMHSA,
2002), but . . .
DSM-V Controversy
Case Example 1
 “Can you prescribe my medication?
 32 year old single woman with a history of ADHD since
college, who is prescribed amphetamines.
 The reason for the office visit is for the purpose of
needing a psychiatrist to manage her medications
 She has a degree in business and works in marketing,
recently in a new position.
 She was treated for an eating disorder when 14 in an
intensive outpatient treatment program, and has
been abstinent from her behavior since college.
The seduction of a
psychiatric diagnosis…..
ADHD and Bipolar disorder
These diagnoses and others share a common theme:
Often missed and/or misdiagnosed/overdiagnosed
Not obvious, under the surface (like a bear in the woods)
Great imitators (like addiction!)
The “eureka” feeling and/or satisfies managed care
paradigm – “Now we have an explanation”
Case example
 Family history is
significant for a father
who “was an alcoholic”
and quit drinking on his
own ten years ago after
consecutive DUI’s.
 She views her
childhood as “normal”
 She has a new
boyfriend, who is a
former professional
wrestler, and who is a
daily marijuana smoker.
 I agreed to prescribe
her medication after
reviewing her
electronic pharmacy
record, which shows
refill pattern consistent
with her history
 “Oh, by the way….She
also takes occasional
Ativan at bedtime
 She doesn’t drink
alcohol.
Shame
 Patient tried to stop her medications on her own due
to feeling “gross” about taking them
 Binges/Purges when doesn’t take her medications
 Identified that she uses relationships like a drug, and
keeps a stash
 Her parents really aren’t sober (Neither is she)
 Neither is she
ACE pyramid
ACE Study continued
 The ACE score, a total sum of the different categories
of ACEs reported by participants, is used to assess
cumulative childhood stress. Study findings repeatedly
reveal a graded dose-response relationship between
ACEs and negative health and well-being outcomes
across the life course.
 Dose-response describes the change in an outcome
(e.g., alcoholism) associated with differing levels of
exposure (or doses) to a stressor (e.g. ACEs). A graded
dose-response means that as the dose of the stressor
increases the intensity of the outcome also increases.
Adverse Childhood Events:
As the number of ACEs increases so does the risk for the following*:

Alcoholism and alcohol abuse

Multiple sexual partners

Chronic obstructive pulmonary
disease

Sexually transmitted diseases

Depression

Smoking

Fetal death

Suicide attempts

Health-related quality of life

Unintended pregnancies

Illicit drug use

Early initiation of smoking

Ischemic heart disease

Early initiation of sexual activity

Liver disease

Adolescent pregnancy

Poor work performance

Risk for sexual violence

Financial stress
Risk for intimate partner violence

Poor academic achievement

Alcoholics Anonymous
What does Attachment
Theory say about Addiction?
 An attempt at self repair that fails (Kohut 1977)
 Addiction further prevents healthy repair from
occurring thru isolation and increased emotional
dysregulation
 Until an addict learns to develop the capacity for
mutually satisfying relationships they are vulnerable to
relapse.
It's hard to be humble when
you're as great as I am.
Muhammad Ali
Healthy Narcissism
 Giving and receiving are balanced
 Recognition of the other in a positive way
 Necessary for healthy self esteem
 NOT a insecure defense against humiliation and
shame
 NOT inflated sense of self
 Healthy dependency on others is accepted
 NOT Codependency or Counterdependency
The brain opioid theory of
social attachment
 Children with poor attachments exhibit lower opiate
receptor density (Flores 2005)
 Kraemer’s (1985) peer monkeys and isolation
syndrome
 Dysregulation of opioid, Serotonin, Dopamine, NE
 FMRI’s of the Brain of patients experiencing pain
compared with patients experiencing rejection/loss
(Eisenberger and Lieberman, 2003)
 Depression and isolation increase Mu activity
Secure versus Insecure
Attachment
 Secure attachment liberates. (Safety permits
play)
 Insecure leads to patterns of either rigidity or
chaos (Siegel)
 Secure attachment maintains homeostasis
 Insecure attachment destabilizes
 Secure attachment is required throughout
the lifespan
 Isolation causes increased stress and poorer
health outcomes across the lifespan
Thanks
 Sarah Acland
 Burns Brady
 Jay Davidson
 Robert Frierson
 Greg Jones
 Arthur Meyer
 Estate Sokhadze