1

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.

2

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

3

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

4

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

5

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.

6

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.

7

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.

0

1

2

3

4

5

6

7

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

8

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.

9

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)

10

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

11

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?

12

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

13

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

14

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

15

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.

16

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 Dcavitt@macmh.org

Phone:(651) 644-7333 Fax: (651) 644-7391