psychiatric aspects of adolescent co-occurring disorders

1

Psychiatric Aspects of Adolescent Psychiatric Aspects of Adolescent Co-occurring Disorders Co-occurring Disorders

Seth Eisenberg MDMedical Director, DHS-DASA

October 24, 2011

2

Eisenberg OutlineEisenberg Outline

Similarities and relationships between AOD and psych symptoms

Mental Status Exam, Diagnosis and Psychiatric Symptoms

Anxiety Disorders Elements of Medication Treatment Adolescent Gambling Ask the Doc

3

AOD Use and Psychiatric Symptoms

AOD use can cause psychiatric symptoms and mimic psychiatric syndromes.

AOD use can initiate or exacerbate a psychiatric disorder.

AOD use can mask psychiatric symptoms and syndromes.

AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes.

Psychiatric and substance use disorders can independently coexist.

Psychiatric behaviors can mimic substance use problems.SAMHSA TIP #9

SAMHSA TIP #9

4

Drugs That Precipitate or Mimic Mood Disorders

Mood DisordersDuring Use

(Intoxication)After Use

(Withdrawal)Depressionand dysthymia

Alcohol,benzodiazepines,opioids, barbiturates,cannabis, steroids(chronic), stimulants(chronic)

Alcohol,benzodiazepines,barbiturates, opiates,steroids (chronic),stimulants (chronic)

Mania andcylothymia

Stimulants, alcohol,hallucinogens,inhalants (organicsolvents), steroids(chronic, acute)

Alcohol,benzodiazepines,barbiturates, opiates,steroids (chronic),

SAMHSA TIP #9

5

Adolescent DependencyAdolescent Dependency

GENERAL EFFECTS

The adolescent demonstrating these behaviors maybe indicating a problem with drugs and/or alcohol:

Sudden, noticeable personality changes Severe mood swings Changing peer groups Dropping out of extra-curricular activities

ADOL-CD Cont’d

6

GENERAL EFFECTSGENERAL EFFECTS

Decreased interest in leisure time activities Worsening grades Irresponsible attitude toward household

jobs and curfews Depressed feelings much of the time Dramatic change in personal hygiene

concern Changes in sleeping or eating habits

ADOL-CD Cont’d

7

GENERAL EFFECTSGENERAL EFFECTS

Smell of alcohol or pot Sudden weight loss Tendency toward increasing dishonesty Trouble with the law Truancy from school

ADOL-CD Cont’d

8

Frequent job losses or changes Turned off attitude if drugs are discussed Missing household money or objects Increasing time alone in his/her room

ADOL-CD Cont’d

GENERAL EFFECTSGENERAL EFFECTS

9

Deteriorating family relationships Drug use paraphernalia, booze, or empty

bottles found hidden Observations of negative behavior by

people within or outside immediate family Obvious signs of physical intoxication

ADOL-CD Cont’d

GENERAL EFFECTSGENERAL EFFECTS

10

Some of these behaviors are a sign of typical adolescent development, BUT,

a wide variety of them in one person should raise suspicions of the likelihood of harmful involvement with drugs or alcohol….

OR—some kind of psychiatric problem

ADOL-CD Cont’d

GENERAL EFFECTSGENERAL EFFECTS

11

Adolescent Comorbidity

The syndrome most consistently associated with substance use is

delinquent behavior,

followed by scales measuring social problems and attention problems

12

The likelihood of substance use among adolescents is associated with the severity of emotional and behavioral problems across age and gender groups.

Adolescent Comorbidity

13

Past-month marijuana use was nearly 2x as likely and use of other drugs was 4x more likely for adolescents with serious emotional problems than for adolescents with low levels of emotional problems.

Adolescent Comorbidity

14

Past-month marijuana use was 4x as likely, and use of other drugs was nearly 7x more likely, for adolescents with serious behavioral problems than for adolescents with low levels of behavioral problems.

Adolescent Comorbidity

15

Dependence on substances such as cocaine, crack, inhalants, hallucinogens, heroin or prescription drugs was nearly 9x as likely among adolescents with serious behavioral problems.

Adolescent Comorbidity

16

Past-month alcohol use was nearly 2x as likely for adolescents with serious emotional problems than for adolescents with low levels of emotional problems.

Adolescent Comorbidity

17

Adolescents with serious behavioral problems were nearly 3x as likely to use alcohol in the past month than adolescents with low levels of behavioral problems

Adolescent Comorbidity

18

Adolescents with serious emotional problems were nearly 4x more likely to be dependent on alcohol or illicit drugs than adolescents with low levels of emotional problems.

Adolescent Comorbidity

19

Alcohol or drug dependence was more likely among adolescents with serious behavioral problems than among adolescents with low levels of behavioral problems

Adolescent Comorbidity

20

Stealing, swearing, hanging around with troublemakers and running away from home -

Feeling confused or in a fog

were associated with more substance use

Adolescent Comorbidity

21

While overall substance use is generally higher for adolescent males than for females, females with high ratings for psychosocial problems as measured by the YSR were as likely as males to smoke cigarettes, binge drink or use illicit drugs.

Adolescent Comorbidity

22

• Juvenile Delinquency• Runaways• High School Dropouts• Youth With Psychiatric Disorders• Unmarried Pregnant Adolescents• Youth That Have Been Physically, Sexually, or Emotionally Abused

Risk Factors

Adolescent Comorbidity

23

• Unsatisfactory Family Relations• Children in Foster Care• Extreme Sexual Activity• Exploited Youth• School Difficulty - Low G.P.A.

Risk Factors

Adolescent Comorbidity

24

• Family Social Deprivation, i.e., Poverty• Association with Delinquent Peers• Neighborhood/Community Disorganization• Affiliation with Peers of Other Dysfunctional Family Systems

Risk Factors

Adolescent Comorbidity

25

• More Impulsive• Less Mature• More Peer Oriented• Restless (tension reduction oriented)

Characteristic Profile

Adolescent Comorbidity

26

• Rebellious• Increased Sadness• Increased Social Withdrawal• Learning Problems

Characteristic Profile

Adolescent Comorbidity

27

Adolescent Chemical DependencyAdolescent Chemical Dependency

Low self esteem Feelings of not belonging Poor coping skills Poor interpersonal skills Poor situational skills, poor judgement Biogenetic factors

ADOL-CD Cont’d

Individual Risk

28

Adolescent ComorbidityWhen Compared to Non-CD Psychiatric Cases

• Earlier First Use of Drugs (14 vs 12)• Increased Divorce (56% vs 26%)• Increased Parental CD• Increased Parental Psychiatric Illness

29

Adolescent ComorbidityWhen Compared to Non-CD Psychiatric Cases

• More Legal Problems• Increased Special Education Placement• More Frequent Suicide Attempts• Increased Residential Placement

30

Adolescent ComorbidityAssociated with:

• Earlier Onset of Abuse Behaviors• Greater Clinical Severity• Poorer Outcomes• Increased Disturbance of Relationships

31

Adolescent ComorbidityAssociated with:

• Differential Responsiveness to CD Treatment• Increased Risk of Relapse• Less than Optimal Functioning when Abstinent

32

Adolescent ComorbidityDiagnostic Considerations

• Impact of Chemical Use decreased withdrawal symptoms varied expression of use negative effect on development

• Emerging Psychiatric Illness usual age of onset precipitating event

33

• Commonality of Symptoms of Psychiatric Disorders

ADHD, bipolar, depression, CD, anxiety

• Confounding Symptoms of Adolescent CD Intoxication Chronic use ABCD-S

Adolescent ComorbidityDiagnostic Considerations

34

Adolescent ComorbidityAdolescent Behavior CD Syndrome

• High Delinquency• Hyperactivity• Decreased School Performance• Decreased Social Competence/Participation• Depressed Behaviors• Onset after development of CD and subsides 2 months after onset of sobriety

35

Adolescent ComorbidityABCD-S (Continued)

• May Result In: developmental dysfunction hyperactivity, distractibility restlessness, impulsivity depression and suicide

• Possible Overdiagnosis of Psychiatric illness

36

Diagnostic DilemmasDiagnostic Dilemmas

Psychoactive substances have profound effects on neurotransmitter systems– Neurotransmitters may be involved in

psychiatric disease states– May unmask genetic vulnerability– May cause a psychiatric disease

It may be difficult to differentiate which diagnosis is primary, ie which “came first”

37

Psychiatric DiagnosisPsychiatric Diagnosis

Mental Status Exam and Psychiatric Symptoms

38

MENTAL STATUS EXAMINATION (MSE)

APPEARANCE

SPEECH

EMOTIONS (mood & affect)

THOUGHT PROCESS

THOUGHT CONTENT

PERCEPTIONS

Formal or MINI MSE

ORIENTATION

MEMORY

CONCENTRATION

INSIGHT

JUDGMENT

IMPULSE CONTROL

39

MENTAL STATUS EXAMINATION (MSE)MENTAL STATUS EXAMINATION (MSE)

Appearance– Physical appearance, mannerisms, attitude

Speech – Rate, rhythm, volume, articulation

Mood– “how do you feel today”

Affect– Outward expression of inner mood: range,

intensity, stability, appropriate

40

MENTAL STATUS EXAMINATION (MSE)MENTAL STATUS EXAMINATION (MSE)

Thought Process– Productivity, continuity, coherence

Thought Content – fears, obsessions, paranoia, suicide, violence

Perceptions– Hallucinations and illusions, depersonalization

Orientation and Cognition (formal MSE)

41

Overview of Psychiatric Disorders Overview of Psychiatric Disorders and Symptomsand Symptoms

Schizophrenia and Psychosis Mood Disorders Anxiety Disorders ADHD and Impulse Control Disorders Personality Disorders Developmental Disorders Sleep Problems

42

Schizophrenia and Schizophrenia and Other Psychotic Disorders Other Psychotic Disorders

Schizophrenia Schizophreniform Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Substance Induced Psychotic Disorder

43

Symptoms of PsychosisSymptoms of Psychosis

Hallucinations Delusions (bizarre and non-bizarre) Disorganized speech Disorganized thinking Disorganized behavior or catatonia “negative symptoms”

44

Antipsychotics/NeurolepticsAntipsychotics/NeurolepticsTraditional—First GenerationTraditional—First Generation

chlorpromazine fluphenazine haloperidol perphenaxzine thioridazine thiothixene trifluoperazine

Thorazine, Prolixin, Haldol (decanoate), Trilafon, Mellaril, Navane, Stelazine

45

Antipsychotics/NeurolepticsAntipsychotics/NeurolepticsAtypical, Novel—Second GenerationAtypical, Novel—Second Generation

aripiprazole clozapine olanzapine quetiapine risperidone ziprasidone

Abilify, Clozaril, Zyprexa (zydis), Seroquel, Risperdal Geodon, Saphris, Fanapt, Latuda

• Consta• Invega Sustena• Relprev

46

Mood DisordersMood Disorders

Depressive Disorders– Major Depressive Disorder– Dysthymic Disorder

BiPolar Disorders– Bipolar I– Bipolar II

Cyclothymic Disorder Substance Induced Mood Disorder

47

Symptoms of DepressionSymptoms of Depression

Depressed mood, sadness, crying Decreased interest and pleasure Decreased energy and activity Weight change, sleep change Low self esteem, worthlessness, guilt Decreased concentration Suicidal ideation

48

ADOLESCENT COMORBIDITYDepression

•Mostly studied - high prevalence in adults•Approximately 80% clear in two weeks•In adolescents - frequent suicidality•Suicide attempts with increased medical seriousness and lethality•Family history important•Developmental history important

49

AAntidepressantsntidepressantsSSRIsSSRIs

citalopram escitalopram fluoxetine fluvoxamine paroxetine setraline

Celexa, Lexapro, Prozac, Prozac weekly, Sarafem

Luvox, Paxil, Paxil CR, Zoloft

Cymbalta, Pristiq, Paxeva

50

AAntidepressantsntidepressantsTricyclicsTricyclics

amitriptyline clomipramine desipramine doxipin imipramine maprotiline nortriptyline protriptyline

Elavil, Anafranil, Norpramin, Sinequan, Tofranil, Ludiomil, Pamelor, Vivactil

51

AAntidepressantsntidepressantsOthersOthers

buproprion mirtazapine trazadone venlafaxline isocarboxazide phenelzine tranylcypromine

Wellbutrin (SR, XL), Remeron, Deseryl, Effexor (ER), Marplan, Nardil, Parnate

52

Symptoms of Bipolar ManiaSymptoms of Bipolar Mania Elevated, expansive mood of well being More irritable or agitated Grandiose delusions Decreased need for sleep More talkative than usual Racing thoughts More action and activity Increased distractibility

53

Antimanic MedicationsAntimanic Medications

lithium carbamazepine divalproex sodium gabapentin lamotrigine oxcarbazepine TopiramateAtypical Antipsychotics

Eskalith, Tegratol, Depakote, Neurontin, Lamictal, Trileptal, Topamax

54

Anxiety DisordersAnxiety Disorders

What is Anxiety?

55

Symptoms of Anxiety

autonomic hyperactivity increased hand tremor insomnia nausea or vomiting psychomotor agitation AnxietyNervous, tense, fearful and high strung

56

Symptoms of AnxietySymptoms of Anxiety

Panic attacks and fear of panic attacks Excessive worry about everything Intrusive memories, flashbacks, fears Excessive anxiety in social situations—fear of

negative judgment and embarrassment Repeating thoughts or behaviors

57

Anxiety DisordersAnxiety Disorders

Panic Disorder--with agoraphobia Social Phobia Generalized Anxiety Disorder Obsessive-Compulsive Disorder Acute Stress Disorder Posttraumatic Stress Disorder Substance-Induced Anxiety Disorder

58

Panic AttackPanic Attack Palpitations, pounding, chest pain/discomfort Sweating Trembling or shaking SOB Feeling of choking Nausea or abdominal distress Dizzy, unsteady, lightheaded or faint Derealization, depersonalization Fear of losing control, going crazy, dying

59

AgoraphobiaAgoraphobia Anxiety about being in places or situations from

which escape might be difficult (or embarrassing) in the event of a panic attack

The situations are avoided or are endured with marked distress

Anxiety or phobic avoidance is not better accounted for by another mental disorder

60

Social PhobiaSocial Phobia Marked and persistent fear of social or performance

situations, possible scrutiny by others or may act in a way that will be embarrassing or humiliating

Exposure to feared social situation provokes anxiety (or may have panic attack)

Person recognizes that the fear is excessive Feared situations are avoided or endured Avoidance, anxious anticipation or distress interferes

with functioning

61

Social Phobia“Marked and persistent fear of social or performance situations in which embarrassment may occur” (DSM

IV)

Prevalence 12% to 56% in alcoholic populations

May interfere with treatment

Specific symptoms for diagnosis

SSRIs (delayed effect)

62

Generalized Anxiety DisorderGeneralized Anxiety Disorder Excessive anxiety and worry (apprehensive

expectation) about number of events occurring more days than not

Difficult to control the worry Associated with three or more frequently present

– Restlessness or feeling keyed up, on edge– Easily fatigued, – Irritability– difficulty concentrating or mind going blank– Muscle tension– Sleep disturbance

63

Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder

Obsessions Recurrent persistent thoughts, impulses or

images—intrusive and inappropriate and cause anxiety or distress

Not simply excessive worries Person attempts to ignore or suppress or

neutralize Recognized as a product of own mind

64

Obsessive-Compulsive DisorderObsessive-Compulsive DisorderCompulsions Repetitive behaviors or mental acts the person feels

driven to perform in response to obsession or according to certain rules

The behaviors or mental acts are aimed a preventing or reducing distress or preventing some dreaded act (not realistic)

At some point are recognized as excessilve or unreasonable

Cause marked distress or are time consuming or significantly interfere

65

Acute Stress DisorderAcute Stress Disorder Exposed to traumatic event with serious threat

and feelings of intense fear, helplessness or horror

During or after event had three or more:– Numbing, detachment or lack of emotions– Reduction in awareness of surroundings– Derealization– Depersonalization – Dissociative amnesia

66

Acute Stress DisorderAcute Stress Disorder Traumatic event is re experienced with

images, thoughts, dreams, flashbacks, reliving or distress with reminders

Marked avoidance of stimuli that remind Marked symptoms of anxiety or increased

arousal (poor sleep, irritable, startle, etc) Causes significant distress or impairment Lasts a minimum of 2 days and maximum of 4

weeks and occurs w/in 4 weeks

67

Post-Traumatic Stress Disorder

“Development of symptoms following exposure to an extreme traumatic stressor” (DSM IV)

30% to 50% prevalence in SUD treatment seekers Goal to reduce key symptoms Target symptom constellations

TCAs and MAOI’s - Depressive and intrusive

Neuroleptics - Psychosis and dissociation Carbamazipine - Impulse dyscontrol Clonidine, Beta Blockers, Benzos -

arousal SSRIs

68

ADOLESCENT COMORBIDITYPTSD

•Child/adolescent sexual and physical abuse•Increased depression, anxiety, negative self concept, suicidal behavior•Adolescent antisocial behavior

69

ADOLESCENT COMORBIDITYPTSD

•Increased school problems, run away, placement, legal difficulties•More drugs with more frequent use•Motivation for substance use

reduce tension sleep relieve pain or discomfort escape family problems

70

Antianxiety MedicationsAntianxiety Medications alprazolam chlordiazepoxide clonazepam diazepam lorazepam oxazepam buspirone propranolol hydroxyzine

Xanex, Librium, Klonopin, Valium, Ativan, Serax, Buspar, Inderal, Atarax (Vistaril)

SSRIsAtypicals

71

Anxiety Disorders and SUDAnxiety Disorders and SUDMedication TreatmentMedication Treatment

Panic Disorder (5-42% in AUD, 7-13% in MMT) SSRI, TCA, MAOI, benzodiazepines all effective

(not studied in COD populations) May have initial activation with SSRI and TCA

that could increase risk of relapse—use low dose initiation

Latency of onset of effect, 2-6 weeks SSRIs—no abuse potential, safe, generally well

tolerated, may help with ETOH

72

Anxiety Disorders and SUDAnxiety Disorders and SUDMedication TreatmentMedication Treatment

Benzos usually avoided in SUD populations (but not an absolute contraindication)

Panic disorder can also be treated with anticonvulsants (valproate or carbamazepine) and Panic with stimulant abuse may respond to these agents due to neuronal sensitization and limbic excitability

TCAs carry risk of lower seizure threshold and interactions with ETOH, depressants and stimulants

73

Anxiety Disorders and SUDAnxiety Disorders and SUDMedication TreatmentMedication Treatment

Social Anxiety Disorder (8-56% in AUD, 14% in cocaine, 6% in MMT)

In most cases SAD precedes AUD so a period of abstinence not so important

Early identification important with COD as SAD may interfere with SUD treatment

SSRI have FDA indication (paroxetine) and may also reduce alcohol use

Venlafaxine and gabapentin

74

Anxiety Disorders and SUDAnxiety Disorders and SUDMedication TreatmentMedication Treatment

Generalized Anxiety Disorder (8-52% in AUD, 21% in MMT, 8% in cocaine)

Diagnostic difficulties—overlap with symptoms of acute intoxication with stimulants and withdrawal from alcohol and sedatives (and anxiety in early recovery--PAWS)

SSRI, TCA, venlafaxine, anticonvulsants Use of benzodiazepines is controversial Buspirone may be effective

75

Comorbid Anxiety and Alcohol Comorbid Anxiety and Alcohol Which Comes First? Which Comes First?

Risk of getting new ETOH Dep as a Jr/Sr more than tripled among students with anxiety dx as a freshman.

Students with ETOH Dep as freshman were 4xmore likely to dev. an anxiety d/o (6yrs)

So having either an anxiety or ETOH d/o earlier in life apears to increase the probability of developing the other later

76

Comorbid Anxiety and Alcohol Comorbid Anxiety and Alcohol Comorbidity ModelsComorbidity Models

1. Having an anxiety disorder predisposes one to develop an SUD via self medication

– “anxiety induced” substance use disorder2. The social, occupational and physiologic

effects of substance use can generate new anxiety symptoms in vulnerables

– Not the same as “substance induced”3. Third factor can serve as a common cause for

both conditions (underlying genetic or physiologic liability)

77

ADHDADHD

Hyperactivity and inattention– Impulsive, overactive, impatient, intrusive– Distracted, poor concentration, procrastinates,

disorganized and forgetful

78

ADOLESCENT COMORBIDITYAttention Deficit/Hyperactivity Disorder

•Differential Diagnosis - bipolar LD Mood and anxiety ABCD-S

•Psychiatric Cormorbidity•Multiple Risks for Substance Abuse•In Adults

79

ADOLESCENT COMORBIDITYAD/HD - Treatment Considerations

•Require Special Programming•Chronic Experience of Failure•Mood Problems - Self Esteem•Disruptive Behaviors•Learning Problems•Difficult family Situations

80

Stimulant MedicationsStimulant Medicationsand Non-Stimulantsand Non-Stimulants

D-amphetamine L & d-amphetamine Methamphetamine Methylphenidate Pemoline Modafinil Atomoxetine Bupropropion Guanefacine-clonidine

Dexedrine, Adderall, Desoxyn, Ritalin, Concerta, Metadate, Focalin, Cylert, Provigil, Strattera, Wellbutrin, TenexIntuniv

81

Personality DisordersPersonality Disorders Antisocial Personality Disorder Paranoid Personality Disorder Schizoid and Schizotypal PD Borderline Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder

82

Developmental and Organic Developmental and Organic DisordersDisorders

Mental Retardation and other syndromes Autism and Asperger’s Learning Disabilities Communication Disorders Tic DisordersCognitive impairment from seizures, traumatic

brain injury, medical, drugs and alcohol

83

Medication Treatment of Psychiatric Medication Treatment of Psychiatric and Substance Use Disorders and Substance Use Disorders

Psychotherapeutic Medications: What Every Counselor Should Know

Mid-America Addictions Technology Transfer Center

84

Medication TreatmentMedication TreatmentGeneral PrinciplesGeneral Principles

Pharmacologic effects: Therapeutic—indicated purpose and

desired outcome Detrimental—unwanted side effects (may

interfere with adherence), potential for abuse and addiction

Need a balance between therapeutic and detrimental

85

Medication TreatmentMedication TreatmentGeneral PrinciplesGeneral Principles

Psychoactive Potential: Ability of some medications to cause distinct change in mood or thought and psychomotor effects– Stimulation, sedation, euphoria– Delusions, hallucinations, illusions – Motor acceleration or retardation

All drugs of abuse are psychoactive

86

Medication TreatmentMedication TreatmentGeneral PrinciplesGeneral Principles

Many medications are non-psychoactive (except for mild side effects including sedation or stimulation)

Not considered euphorigenic( although can be misused and abused)

Psychoactive drugs considered high risk for abuse and addiction

Some psychoactive meds have less addiction potential (old antihistimines)

87

Medication TreatmentMedication TreatmentGeneral PrinciplesGeneral Principles

Positive reinforcement—increase the likelihood of repeated use– Amplification of positive symptoms or states– Removal of negative symptoms or conditions– Faster reinforcement, more prone to misuse

Tolerance and Withdrawal– Higher risk for abuse and addiction

More concerns when prescribing to high-risk patients

88

Medication TreatmentMedication TreatmentStepwise Treatment Model Stepwise Treatment Model

Risks/benefits analysis (risk of medication, risk of untreated condition, interactions, potential for therapeutic benefits)

Early and aggressive treatment of severe psychiatric problems

Start with more conservative approach with high risk patients and less severe conditions

89

Medication TreatmentMedication TreatmentStepwise Treatment ModelStepwise Treatment Model

High risk patients with anxiety disorder1. Non-pharmacologic approaches when

possible2. Non-psychoactive medications added next as

adjunctive treatment 3. Psychoactive medications when other

treatments fail

90

Medication TreatmentMedication TreatmentStepwise Treatment ModelStepwise Treatment Model

Non-pharmacologic approaches– Psychotherapy, cognitive and behavioral tx, stress

management skills, medication, exercise biofeedback, acupuncture, education, etc

Use meds with low abuse potential Conservative approach not the same as under-

medicating Different treatments should be complementary,

not competitive

91

Talking to Patients about MedicationsTalking to Patients about Medications

Make an inquiry every few sessions Are their Psych meds. Helpful? How? How many doses or how often do you miss? Acknowledge that taking pills everyday is a

hassle and everybody misses sometimes Did they feel or act different? Or use? Explore connections of MH, meds, use Forget? Or choose not to take it.

92

Medication AdherenceMedication AdherenceComorbid SUD: a Risk for Non-adherence Comorbid SUD: a Risk for Non-adherence

May have conflicted feelings and attitudes about medication

Meds may be sometimes discouraged or thought to be un-needed

See it as a sign of weakness May stop meds during relapse May misused meds

93

Talking to Patients about MedicationsTalking to Patients about Medications

Problem solve strategies to not forget– Use a pill box, help set it up– Keep it where it cannot be missed or avoided– Link med taking with some daily activity– Use an alarm clock set for the time to take– Ask someone to help them take meds

94

Talking to Patients about MedicationsTalking to Patients about Medications Some patients may choose not to take meds

– They have a right to make that choice– Owe it to themselves to make sure their important

health decision is well thought out– Explore-- “I just don’t like pills (or meds)”. – Elicit a reason—never needed it, cured now, don’t

believe in it, means I’m crazy, side effects, afraid, shame, cost, interpersonal, want to be in control, do it on my own, can’t use

– Motivational Interviewing

95

Using an Empathic StyleUsing an Empathic Style

An Empathic Style Communicates respect for and acceptance of

clients and their feelings Encourages a nonjudgmental, collaborative

relationship Allows the clinician to be a supportive and

knowledgeable consultant

96

Using an Empathic StyleUsing an Empathic Style

An Empathic Style Compliments and reinforces the client

whenever possible Listens rather than tells Gently persuades, with the understanding

that the decision to change is the client’s Provides support throughout the recovery

process

97

Motives for AdolescentGambling Behavior

RelaxationEnjoyment, Excitement, EntertainmentAdventure, AttentionOpportunityNegative feelings

98

Why Do Youth Gamble?Why Do Youth Gamble?

Excitement Entertainment Escape Economics Ego

99

Psychiatric ComorbidityPsychiatric ComorbidityEffects of Family GamblingEffects of Family Gambling

May be effected directly or indirectly Impact on kids depends on how disorganized or

dysfunctional the family is to begin with and how much gambling disrupts family routines

Impact is greater if parents are pulled away from their roles as caretakers

Impact on children also related to:– .Age of children– .Underlying personalities and character– .Amount of marital discord

100

Psychiatric ComorbidityPsychiatric ComorbidityEffects of Family GamblingEffects of Family Gambling

Children may feel responsible for things they don’t understand and become anxious and guilt ridden—they may develop certain roles they play in the family

Children may get pulled into deceit and subterfuge by the gambler parent

Experience may ultimately shape the child’s values about money

Children may manifest a wide variety of behaviors and moods at home, at school or in the community

101

Psychiatric ComorbidityPsychiatric Comorbidity

Most consistent finding is depression Themes of guilt, self-punishment Hopelessness, lack of motivation, suicide

and loneliness Self-destructive excessive risk-taking Significant life events before depression 2/3 of life events after gambling Subsets of gamblers

102

Psychiatric ComorbidityPsychiatric ComorbidityDSM-IVDSM-IV

Depression-with high suicidality Bipolar Disorder and Cyclothymia ADHD Personality Disorders (APD, NPD, BPD) General medical conditions with stress Substance use disorders Urge to gamble increases during periods of

stress or depression

103

Psychiatric ComorbidityPsychiatric ComorbidityPsychiatric Typology-Psychiatric Typology-BlaszczynskiBlaszczynski

“Normal” problem gamblers Emotionally disturbed gamblers Biological correlates of gambling

104

Pathological Gambling and Pathological Gambling and Substance AbuseSubstance Abuse

More severe substance abuse history More episodes of overdose More prior AOD treatment Used a greater variety of drugs Greater past use of ETOH, opiates and

solvents Greater history of legal problems

105

Why Harm ReductionWhy Harm Reductionfor Adolescent Gamblingfor Adolescent Gambling

Gambling is a SOCIALLY ACCEPTABLE ACTIVITY

Entertainment Unique: no social barriers Promoted in the home environment

106

Adolescent Chemical DependencyTreatment and Outcomes

•Multidimensional and multidisciplinary•Developmental status - habilitation vs. rehabilitation

•Flexibility - stages of change•Family therapy - family issues•Treatment programs - long term OP vs. short term inpatient

107

Adolescent Chemical DependencyTreatment and Outcomes

•Treatment completion, parental involve- ment and aftercare

•Good social supports, self esteem and coping skills

•Greatest relapse risk during first 3 months (>60%)

•Relapse associated with delinquency, social and peer influence, drug craving, less productive and recreational activities

108

Ask the DocAsk the Doc