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Adolescents with Chemical Dependency
and Mental Illness
Addressing the Complexities
of Dual Diagnosis
Our Mission:
Promote the positive mental health
of all infants, children, adolescents,
and their families.
Our Objectives:
! !Educate the public to remove the stigma & barriers
! !Educate families about multiple systems & how to navigate
! !Opportunities for parents & caregivers to develop care & advocacy skills
! !Inform & educate professionals about children's mental health.
! !Advocate for the timely & appropriate delivery of services to children
! !Provide programs & advocate for services meeting culturally specific needs.
The proverbial question of what came first:
The Mental Health Problem?
Or the Substance Abuse?
It Depends…
• !Sometimes the person suffering from a mental health disorder may take drugs to
alleviate their symptoms- a practice know as self-medicating.
• !In other cases mental health disorders are caused by substance abuse.
• !Finally chronic substance abuse and mental health disorders may exist completely
independent of each other.
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Chemical Dependence and Mental Illness:
A Complex Relationship
DEPRESSION could lead someone
to self-medicate with ALCOHOL for
temporary relief of their pain.
An ANXIETY DISORDER may lead
to trouble sleeping and misuse of
TRANQUILIZERS.
POST-TRAUMATIC STRESS
DISORDER from childhood sexual
abuse may cause a teen to use
MARIJUANA to cope with
the haunting memories.
Hand in Hand MI & CD
Incidence of MI & CD Co-occuring Disorder Facts
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Traditional treatment methods
Traditional treatment for
Mental Illness was supportive,
benign and non-threatening.
MI treatment was intended to support the client’s already fragile defenses.
Traditional treatment methods
Developing a new paradigm
CD MI
Chemical Dependency- Drug Addiction
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Unique Considerations for Adolescents
Increased risk taking and sensation seeking
Sensitivity to immediate rewards & peer group
Significant “rewiring” with alterations in emotions, behaviors, and cognition throughout adolescence
Adolescent transitions trigger more risk for substance abuse and mental health disorders.
The Risk of Being a Teen
• !Overproduction And
Elimination Of Synapses
• !Second Wave Of Synapse
Growth At Puberty
• !Pruning Back Of Synapses
In Adolescence
• !Waves Of Growth In The Corpus
Callosum
• !Substance Use Interferes With
The Normal Trajectory of Brain Development
Brain Changes into Adolescence
" !75% of high school seniors
have tried alcohol
" !50% of high school seniors have
tried at least one illicit drug
" !Heavy alcohol and drug use in adolescents is associated with neuro-cognitive and brain response deficits. " !Adolescents who drink have smaller
amygdalas and smaller hippocampus
" !Binge drinking in teens is correlated with poorer test results, memory and
visual spatial functioning
Adolescent Substance Use
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POOR JUDGMENT !
DESTABILIZES
MENTAL ILLNESS!
ABUSE ILLICIT
DRUGS!
REVERSE EFFECTS!
EUPHORIA
TURNS
INTO
DEPRESSION
More issues with alcohol
HOSPITALIZATION !
HOMELESSNESS!
VIOLENCE!
VICTIMIZATION!
INCARCERATION
! SUICIDAL BEHAVIOR
!"#$%$"!&$'($)')*!
DEATH
Anxiety
Insomnia
Depression
Nausea
Headache
Tremor
Vomiting
Fever
High blood pressure
Seizures
Delirium tremens
Alcohol withdrawal
Drug and alcohol abuse can disrupt brain function
such as motivation, memory, learning, judgment and
behavior control leading to poor academic performance,
health-related problems, and involvement with
the juvenile justice system.
Introducing drugs and alcohol while the
brain is still developing may have
profound long-lasting consequences.
Altered Brain Development Dopamine & The Brain‘s Reward System
The limbic system contains the brain’s reward circuit
Feeling pleasure motivates us to repeat behaviors
that are critical to our existence-like eating and sex
All drugs of abuse target the brain’s reward system by
flooding the circuit with dopamine.
Dopamine is the neurotransmitter present in regions of
the brain that regulate movement, emotions, cognition,
motivation, and feelings of pleasure.
Overstimulation of the system by drugs of abuse initially
produces euphoric effects which encourages users to
repeat the behavior.
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The impact of dopamine drops
as the tolerance level rises causing
the user to have withdrawal symptoms when not using, creating a need
to take more and more drugs to bring
the dopamine function back to normal.
Drug abuse may lead to profound permanent damage in neurons and brain circuits.
Teens are especially vulnerable due to
damage to a brain that is not fully developed.
Significant negative effects on the
brain
Addiction is a Mental Illness
“Addiction changes the brain
in fundamental ways, disturbing
a person’s normal hierarchy
of needs and desires,
substituting new priorities
connected with procuring
and using the drug.
The resulting compulsive
behaviors override the ability
to control impulses despite
the consequences are similar
to hallmarks of other
mental illnesses.”
(NIDA, 2008)
COCAINE blocks the removal of dopamine from
the synapse by binding to the dopamine
transporters resulting in a buildup of dopamine
in the synapse.
Cocaine can release between 2-10 times the
dopamine that natural rewards do.
The brain adjusts by producing less dopamine or
reducing the number of receptors.
Dopamine Depletion
Normal
Cocaine Abuser (10 days)
Cocaine Abuser (100 days)
Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes
in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased
dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.
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Serotonin
The normal activation of serotonin receptors keeps our psychological
and physiological function on an even keel, so we have a normal
mood and we are calm. Using the drug ECSTASY causes a sustained
increase in the amount of serotonin in the synaptic space, leading to
sustained activation of more serotonin receptors. This can produce an
elevated mood (or euphoria). Eventually, the serotonin neurons can’t
make serotonin fast enough to replace that which was lost, so once
ecstasy is gone from the body less serotonin is released with each
electrical impulse and fewer serotonin receptors are activated,
producing depression, anxiety and memory disruption.
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8Depression
Anxiety
ConductDisorders
ADHD
Schizophrenia
Autism/PDD
An estimated 26.2% of Americans over 18 suffer
from mental health disorders in a given year with
anxiety disorders being the most common.
Half of all serious adult disorders start by age 14
with three-fourths present by 25 years of age.
Anxiety Disorder
Those diagnosed with anxiety disorder
are twice as likely than the norm to
have a drug use disorder.
Many young people with anxiety disorder
gravitate towards alcohol abuse.
People with anxiety disorder have the
highest rate of self medication.
Unfortunately it creates a short term relief
But drug use masks anxiety and makes
anxiety worse as the dependence on the
substance creates cravings and withdrawal
symptoms.
A teenager may!
physically resemble !
an adult but still lack !
the brain maturation!
to think and act like one. !
Thus, expecting adolescents to make !
adult-like decisions in regard to the !
use of substances is an unrealistic
expectation for most teenagers.!
In the Process of Becoming
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Asked what most concerned her about
the health of today’s students overall,
Sandi Delack, President of the
National Association of School Nurses said,
“Mental health concerns — by far.
We live in such a high-pressure society,
and more kids than ever are dealing with anxiety,
depression and the tolls of everyday stress,” she said.
“I see the impact every single day, and while there
are certainly other issues, like eating problems and
drugs and drinking, you have to ask yourself —
how much of this is related to what’s going on
emotionally?”
Underlying Mental Health Concerns
Teens abuse prescription !drugs to dull emotional !
challenges of being a teenager. !Prescriptions are easier to lay !
hands on than cigarettes, !beer and street drugs. !
Every day, 2,500 teenagers !use a prescription drug to !get high for the first time. !
Accessing these drugs ! can be as easy as opening !
a cupboard, drawer, !or medicine cabinet !in their own home.!
Teens and Prescription Drug Abuse
ADD/ADHD and Dual Diagnosis
ADHD is a neurobiological disorder with
symptoms of inattention, impulsivity,
hyperactivity and
low frustration tolerance.
There is a 50% chance of drug
abuse with untreated ADD/ADHD.
Young people with ADD/ADHD
are at higher risk for:
• !15% more bi-polar
• !18% more Tourettes
• !25-40% more learning disorders
• !40% more ODD
• !35% more anxiety and depression
• !40-50% more likely to abuse alcohol
ADHD Treatment Success
When individuals are treated for ADD/ADHD there
is 72% Less risk of substance abuse.
Unfortunately only 25% of kids with ADD/ADHD
are getting proper treatment.
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Depression in Adolescents
The peak age of onset
For major depression in
Adolescents is 15 with twice
as many girls affected as boys
Symptoms may include feeling sad, hopeless,
empty, crying, lethargic, slow moving, sleepy,
extremely sensitive, highly reactive to rejection or
criticism, irritable, grouchy, overreacting to
disappointment, restless, aggressive, isolating, being
self destructive, stop caring about appearance, and
high risk of self-medicating with drugs and alcohol.
Co-occurring Disorders and Depression
Fifty percent of adolescents with major
Depression have anxiety disorder which
increases the risk of suicide.
90% percent of adolescents who commit
Suicide have a psychiatric diagnosis of
mood disorder and alcohol /substance abuse.
One in ten patients with borderline personality
disorder completes suicide.
Schizophrenia and Substance Abuse
Schizophrenia has a co-morbidity rate
With substance abuse of 70%, and with tobacco
Use of 90%. Nicotine may counteract psychotic
symptoms and other drugs such as heroin and
Alcohol have been said to, “Stop the voices”.
The mental disorder associated
in brain activity may increase
vulnerability to abusing
drugs by enhancing their
positive effects and
reducing awareness
of their negative effects.
Marijuana and Psychosis
Frequent marijuana use can
increase the use of psychosis
in in individuals who carry a
variant gene. The gene
regulates an enzyme that
breaks down dopamine
A brain chemical involved
in schizophrenia.
Those with the gene have a
higher risk of developing
schizophrenic type disorders
If they used cannabis during adolescence.
(NIDA,2008)
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Marijuana and Psychosis
Sanjiv Kumra, head of the U of M Division of Child &
Adolescent Psychiatry, co-led a study that found adolescents
who smoke a lot of marijuana shared similar white matter abnormalities as those
observed in teenagers with schizophrenia. The study
suggests that heavy marijuana use may hasten the onset of schizophrenia in those
who are genetically predisposed to it.
Marijuana and Psychosis
U of MN researchers using MRI found
differences that distinguish schizophrenia
present in myelin.
Myelin is made up of neuronal pathways
that connect all major brain regions.
Disruption has profound implications.
Neurons that make up these pathways
are coated with myelin making it possible
for neurons to send messages efficiently.
When myelin is not in good shape,
messages are garbled.
Other Marijuana Issues
Increased appetite,
Reduced motor
performance
Reduced attention,
concentration and memory
Loss of interest
and motivation,
Impaired cognition
Visual distortions
Time distortion,
Withdrawal symptoms of
insomnia, anxiety, irritability
Impaired immune function,
Heart problems Lung cancer
Stimulant Abuse and Mental Illness
Hyperawareness & agitation
Hypersexuality
Insomnia
Anorexia
Obsessive compulsive behavior
Anxiety & paranoia
Psychosis
Mania
Intense craving
Withdrawal “crash”
Suicidal ideation
Confusion & Disorientation
Seizures, Strokes, Heart Attacks
Cardiac Arrhythmia
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Opiate Abuse and Mental Illness
Initially provides relief from anxiety
calm, soothing, sleep inducing
Used for self medicating to cope with stress
Feelings of intense pleasure-relief from depression
For some opiates dull the psychosis, stop the voices
False sense of security
Escape from PTSD symptoms
Opiate abuse problems:
HIV/AIDs, Hepatitis,
prostitution, poor hygiene,
malnourishment
Job loss, homelessness
Severe withdrawal symptoms
Overdose, coma, death
PTSD & Substance Abuse
Post Traumatic Stress Disorder
And
Substance Abuse Comorbidity
is frequent and devastating.
Alcohol, opiates, marijuana,
and other sedatives help
to dull the emotional pain
caused by the trauma.
Dual diagnosis places the individual
at a much greater risk of a
marginalized
existence including homelessness,
Prostitution, crime,
and being further victimized.
The trouble with stigma
Society tends to view the person
with mental illness and drug
addiction as an individual
who lacks willpower and
deserves his situation.
The young person with dual
diagnosis may feel shame and
guilt and low self esteem due to
the struggle with the addiction
and mental health disorders.
A moralistic zero tolerance
attitude denies the individual of
the caring commitment
needed from family and
providers in order to recover.
What doesn’t work for dual diagnosis
Tough Love Hitting Bottom
Confrontation, Kicking Them Out
Begging Pleading Nagging,
Bullying Threatening
Embarrassing Ordering Them to Quit
Zero Tolerance
Punishment
Would we do all the above to someone
with diabetes, asthma, or epilepsy?
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Chronic Health Condition
Mental Illness and Addiction
Are chronic diseases that
are controlled, not cured,
just like diabetes and asthma.
The repair process depends
on the individual’s genetic makeup,
the extent of damage to the brain,
the age of onset and length of use,
the type of substance used,
the support of family
and community in recovery,
educating the individual in
understanding and managing the illness.
Guiding Principles in Treating Dual Diagnosis
1. ! Employ a recovery perspective
2. ! Adopt a multi-problem view point
3. ! Develop a phased approach to treatment
4. ! Address specific real-life problems
early in treatment
5. Plan for the client’s cognitive and
functional impairments
6. Use support systems to maintain
and extend treatment effectiveness
TIP 42-CSAT
Essential in a Recovery Oriented System
Hope & optimism
Strength & asset based
Client centered & directed
Empowering & engaging
Holistic & wellness focus
Family Voice & involvement
Responsive to culture & faith
Build self esteem
Evidence Based
Age and gender appropriate with developmental
continuum
Provide social opportunities & connectedness
Least Restrictive
Environment
Outcomes Driven
Nonlinear addressing
relapse
Wraparound
Range of services
support multiple domains
Specialized recovery supports
Reciprocity youth giving
back to community
Future orientation long
term perspective
Opportunity to take risks, fail and learn from
mistakes
Develop a Therapeutic Relationship
Demonstrate understanding
and acceptance of the young client
Help the young person clarify the
nature of his difficulty
Indicate that you are working TOGETHER
Express empathy and a willingness to listen
To the young person’s formulation of the problem
Foster HOPE for positive change
Assist the young person to solve some external
problems directly and immediately
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Approaches for Recovery Perspective
" !Assess the Client’s stage of change
" !Ensure the Treatment Stage is consistent
" !With the client’s stage of change
" !Use client empowerment as motivation for change
" !Foster continuous support
" !Provide continuity of treatment
" !Recognize that recovery is a long-term process
" !Applaud small gains
" !Relapse is normal and not a complete setback
.!
Precontemplation Stage
" !Express concern about the young person’s
mood, anxiety or other symptoms
" !State non judgmentally that you are
aware of the problem
" !Agree to disagree about the severity
of the problems
" !Explore the youth’s perceptions of
the problem
" !Present the person with information about
the symptoms and substance problems
" !Emphasize your commitment to listen
and help
" !Assure the person that you are there for them
" !Share examples of others that have
struggled and recovered
Contemplation Stage
" !Elicit Positive and Negative Aspects of Use
" !Ask about past positive and negative
Periods of abstinence and substance use,
depression, mania, and other symptoms
" !Summarize the person’s comments on the
Mental health and substance abuse episodes
" !Make explicit discrepancies between
values and actions
" !Consider trial abstinence and psychological
evaluation
Preparation Stage " !Acknowledge the significance and courage of the
client’s decision to seek treatment for the disorders
" !Support self-efficacy with regard to each of
the disorders
" !Affirm the young person’s ability to seek treatment
successfully for each of the disorders
" !Help the young person decide on an appropriate
achievable action for each of his or her disorders
" !Caution that the road ahead is going to be tough but very important
" !Explain that relapse will not disrupt the relationship
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Action Stage
Remember the young person may be in the action stage with one disorder
but only in contemplation for another disorder
Adapt your work accordingly and be a source of encouragement and
support
Acknowledge the discomforts of withdrawal and other psychological
symptoms
Reinforce the importance of remaining in recovery for both problems
Maintenance Stage
Anticipate and address difficulties as a
means of relapse prevention
Recognize the young person’s struggle with
either or both problems and engage a team of
specialists for either mental health or
substance
abuse as needed
Support the client’s resolve
Reiterate that relapse or psychological
symptoms will not disrupt the counseling
relationship
Relapse
Explore what can be learned from the relapse
Express concern and mutual empathetic
Disappointment at the relapse
Emphasize the positive aspect of the effort to seek care
Support the young person’s self-efficacy
So that recovery seems achievable
Don’t give up on the young person,
EVER
Let them know you are committed to
Helping them with their ongoing maintenance
And work with recovery!
Promising Treatment Tools For Teens
Cognitive Behavioral Therapy
Dialectical Behavioral Therapy
Motivational Enhancement/Stages of Change
Medication Management
Multi-systemic Therapy
Strategic Family Therapy
Therapeutic Communities
Assertive Community Treatment
Exposure Therapy
Prime for Life Curriculum
Integrated Group Therapy
Dual Recovery Support Group
Ongoing individual outpatient counseling
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Removing Barriers for Recovery
Key Factors- Empathy, Trust,
Warmth, Acceptance, Atmosphere conducive
To Disclosure, Engage the Client as a
Partner in in the process, Develop Discrepancy,
Recognize the Positive as well as negative
Experiences with drug abuse
Avoid argumentation
Respect the young
Persons opinions
Roll with resistance
Support self-efficacy
Be non-confrontational
Maintain the relationship
In the tough times
Screening and Assessment
Screening determines the likelihood that a teen
has co-occurring disorders by asking about signs,
symptoms, or behaviors that may be influenced
by both mental health problems and substance abuse.
Assessment gathers information to determine
readiness for change, strengths or problem areas,
and appropriate setting and treatment plan.
Treatment Planning develops a
Comprehensive set of staged,
integrated program placements
and treatment interventions.
The plan is matched to the
individual’s needs, personal preferences
and goals.
Example of Dual Diagnosis Screening Tool
The Global Appraisal of Individual Needs
The GAIN-Q is an example of an excellent tool for
screening for dual diagnosis and other
Individual needs.
Areas of inquiry are:
General Factors-problems, treatment history
Sources of Stress-Family, Others, violence, School
Physical Health- weight gain or loss, illness, injury
Emotional Health- Anxiety, depression, distress
Behavioral Health-AHDH, ODD, Criminal
Substance Related Issues- Quantity, Frequency,
Choice Service Utilization- ER, Residential,
Outpatient, Medication Readiness for change
Dual Diagnosis Recovery
Dual Diagnosis Recovery is to:
" !Develop skills to overcome both illnesses
" !Learning new meaning in life beyond the illnesses
" !Pursuing meaningful life goals despite symptoms
" !Reducing substance use to minimize distress
and impairment in functioning
" !Reduce symptoms of mental illness such that
Impairment is no longer present.
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Helpful Medications
Disulfiram alcohol
5-10 minutes after drinking alcohol, the patient experiences severe nausea, vomiting and
headache for 30 minutes to several hours.
Naltrexone alcohol and opiates
Blocks opiate receptors, preventing dopamine release. Because the addict no longer receives
pleasure from the drug, cravings diminish.
Methadone and LAAM (Levo-alpha-acetylmethadol) opiates
Work on the same receptor as heroin, but with much more gradual "ups" and "downs" and
longer-lasting effects. Reduces cravings and block the effects of opiates.
Acamprosate alcohol
Decreases the irritability characteristic of early recovery and decreases the pleasurable
effects of alcohol. It most likely works by stabilizing the activity of the neurotransmitters GABA
and glutamate in the brain.
Buprenorphine/naloxone opiates A combination of two drugs that reduces craving and blocks the effects of
opiates. Unlike methadone, it has mild withdrawal effects. The University of Utah (2009)
Tip 42 Substance Abuse Treatment For Persons With Co-Occuring Disorders
SAMHSA
Hills, Holly, Ph.D. (2007) Treating Adolescents with Co-Occuring Disorders.
Florida Certification Board/Southern Coast ATTC Monograph Series #2
Dual Diagnosis and Young People NSW Association for Adolescent Health
(2003)
The University of Utah. (2009) Mental Illness: The Challenge of Dual Diagnosis. learn.genetics.utah.edu/content/addiction/.../mentalillness.html
Boesky, L. (2007). When to Worry: How To Tell if Your Teen Needs Help
And What to Do About It. New York: AMACOM.
Carter, R. and Golant,S.K. (1998). Helping Someone With A Mental Illness.
New York: Random House.
Cataldi, L. (2009). Stay Close: A Mother’s Story of Her Son’s Addiction.
New York: St. Martin’s Press.
SAMHSA, (2009). Designing a Recovery Oriented Care Model for Adolescents
and Transition Age Youth with Substance Use or Co-Occuring Mental Health
Disorders
Resources
National Institute on Drug Abuse.
The Brain: Understanding Neurobiology Through the Study of Addiction (
http://science-education.nih.gov/Customers.nsf/highschool.htm):NIH Pub. No. 00-4871.
National Institute on Drug Abuse. Brain Power! The NIDA Junior Scientists Program (
http://www.nida.nih.gov/JSP/JSP.html):NIH Pub. No. 01-4575. Bethesda, MD: NIDA, NIH, DHHS. 2000.
National Institute on Drug Abuse.
Mind Over Matter: The Brain's Response to Drugs Teacher's Guide (
http://teens.drugabuse.gov/mom/tg_intro.php):NIH Pub. No. 020-3592. Bethesda, MD: NIDA, NIH,
DHHS. Printed 1997. Reprinted 1998, 2002. Revised 2000.
National Institute on Drug Abuse. NIDA InfoFacts: Drug Addiction Treatment Methods (
http://www.drugabuse.gov/infofax/treatmeth.html):Bethesda, MD: NIDA, NIH, DHHS. Retrieved June
2003.
• !Join Together http://www.jointogether.org/
• !http://science.education.nih.gov/
• !NIDA for Teens The Science Behind Drug Abuse http://teens.drugabuse.gov/
• !!Brain Power! The NIDA Junior Scientist Program
• !http://www.drugabuse.gov/JSP/JSP.html
• !NIDA Infofacts: Understanding Drug Abuse and Addiction
• !http://www.drugabuse.gov/Infofax/understand.html
Resources MACMH Training Services
Thank you from your presenter, Deborah Cavitt
Minnesota Association for Children’s Mental Health 165 Western Avenue N, Suite 2
Saint Paul, MN 55102
www.macmh.org [email protected]
Phone:(651) 644-7333 Fax: (651) 644-7391