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Dual Diagnosis Case Studies Mark Holland PhD Consultant Nurse Manchester Mental Health & Social Care Trust 14.3.12 Leeds Dual Diagnosis Network.

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Presentation on theme: "Dual Diagnosis Case Studies Mark Holland PhD Consultant Nurse Manchester Mental Health & Social Care Trust 14.3.12 Leeds Dual Diagnosis Network."— Presentation transcript:

1 Dual Diagnosis Case Studies Mark Holland PhD Consultant Nurse Manchester Mental Health & Social Care Trust Leeds Dual Diagnosis Network

2 Introduction Background care cluster 16 (dual diagnosis of severe mental illness and substance misuse) Cluster 16 needs and treatment guide Case studies Dual diagnosis beyond psychotic cluster 16 Discussion and Conclusion

3 Cluster 16 Cluster Description : This group has enduring, moderate to severe psychotic or affective symptoms with unstable, chaotic lifestyles and coexisting substance misuse. They may present a risk to self and others and engage poorly with services. Role functioning is often globally impaired Diagnoses: F (Schizophrenia, schizotypal & delusional disorders) F30 – 31 (Bi-Polar Disorder) F32.3 (Severe depressive episode with psychotic symptoms) Plus/with F10 – 19 (Mental & behavioural disorders due to psychoactive substance use) Risk : Overdose (intentional/accidental) Entry into CJS Harm to self Harm to others/From others Course: Long term – 3 yrs +

4 C 16 Expected Needs Medication management/pharmacology Health education/harm minimization Engagement Motivational interviewing Social inclusion

5 C 16 Partnership working Substance misuse services (all sectors) CJS (probation/prisons/police) Housing Employment

6 Core Elements of Care Direct Engagement, Motivational interviewing techniques, CBT techniques, Harm minimisation/health promotion, Assertive Outreach Approach, Medication management, Assistance to increase social functioning, Relapse prevention strategies, As appropriate, advise/signpost/access self-help (e.g. groups), self-monitoring (e.g. triggers, early warning signs), Indirect Supportive & empathic relationships, provide hope

7 C16 Pathway Needs CRISIS MANAGEMENT Management of intoxication Mental health relapse CARE COORDINATION Should be under mental health service CPA Care coordination by someone experienced (level 3 capability framework) Drug/alcohol relapse MONITORING OF PHYSICAL AND MENTAL HEALTH This should be the same as the other psychotic clusters with minimum of neuroleptic therapy NICE guide and attendance to BBV treatments and advice DETOX & REHAB Access to detox (complex cases capability) Admission to appropriate complex needs rehabilitation

8 C16 QUALITY AND OUTCOMES GOALS Maximise quality of life and physical health Maintain appropriate contact (SBNT) Symptom management Prevent general worsening of condition Reduce risks (including Safeguarding) Support recovery hopes (both domains) Relapse prevention (both domains) Preventing complications associated with illness and medication as relevant (harm reduction and health promotion/ illness prevention)

9 Case Presentation 1: Christian General implications and exercise / discussion

10 Demographic 24 year old male Caucasian Lives between parents and girlfriends Has a 2 year old child Has a 14 year old brother Unemployed for 18 months, prior to onset of psychosis held various ‘blue collar’ jobs Prison age 20 (violent offence in organised crime, served 3 years)

11 Past History Moderate alcohol Cannabis age 15 to present – Initially symptom free Cocaine age 17 intermittent, no use for past 6 months – Noted by family to be intense in manner and hold emphatic beliefs about Free Masons and Illuminati Heavier cocaine use late teens – Became involved in crime No IV use, no BBV’s despite long term shared insufflation Abstained whilst in prison – No treatment in prison, no reported symptomatology On release drinking increased – Family raised concerns with GP about growing preoccupation with Illuminati and expression of related paranoid ideas, grandiose flavour

12 Past History 22/23 Concerns Putting out cigarettes on forearms Isolating himself Striking his girlfriend Shouting at family (HEE reaction / household) Increased alcohol use Little cocaine or cannabis use Referred to CRHT, poor engagement both parties but ‘calmer’ Referred to dual diagnosis service (DDS)

13 DDS Presentation Type I Diabetes No residual self harm damage or acts FTD, True auditory hallucinations, paranoid delusions with grandiose overtones, derealisation, depersonalisation, with ?Capgras syndrome Generalised anxiety both motor and autonomic Variable mood (prominent paranoia = low mood versus prominent grandiosity – high mood) Verbal expressions of anger towards family and girlfriend (HEE environment) Isolating himself Alcohol used to avoid/reduce anger and alleviate anxiety Anxiety correlates to delusional beliefs (even when grandiose) Disturbed / reversed sleep pattern Increasing alcohol misuse (relief drinking noted) and complications Fluctuating rapport from guarded and suspicious to engaging (desperate for help)

14 Provisional Diagnosis and Management Paranoid Schizophrenia / alcohol induced psychotic disorder with hallucinations and delusions Alcohol harmful use / dependence syndrome Neuroleptic Therapy Vitamin Therapy Motivational Interviewing – Alcohol education and information – Alcohol reduction / detox (community/ inpt) CMHT referral Alcohol Service referral?

15 Exercise In groups or pairs please list the possible additional issues – E.g. Safeguarding, risk to staff, other services for cannabis, cocaine and other drugs, engagement issues, individual / family CBT etc List issues that have emerged in your practice with similar patients List services you have referred to or know of that may help Christian

16 Case Presentation 2: Kelly Motivational interviewing / Cognitive behavioural approach for distress, symptoms, motivation and coping

17 17 Overview 29 year old woman 2 nd generation African Caribbean Lives alone in well kept flat 2 friends, one of whom visits 5 times a week Pet cat Limited contact with adoptive parents or siblings (all white British) for past 6 or 7 years Split from them was acrimonious (elements of illness associated) Diagnosed paranoid schizophrenia 6 years ago Previous schizotypal personality disorder diagnosed (PD label has stuck) Receives fortnightly risperidone consta 37.5mg On 3 rd antidepressant Smokes skunkweed daily Crack cocaine and heroin smoked as treat fortnightly Hep C (prior IV use)

18 18 Mental health distress Paranoid feelings – constant and pre curser to… …Paranoid ideation – conviction level increases rapidly when outside among strangers and friends alike General anxiety – psychomotor and autonomic Social anxiety / phobia Marked depression Anger – specific to adoptive parents or at times of paranoid ideas of reference Feelings of rage – free floating (and sometimes attached to adoptive family)

19 19 Paranoid ideation No consistent delusional belief elicited Feels under constant surveillance but guarded when describing / cannot elaborate (most days, throughout the day) Manageable when smoking cannabis and in her flat Ideas of reference from variety of sources when out Not specific to same individuals or groups History of violent response (stabbed a male stranger who voices said had raped her) Accompanied by true auditory hallucinations Paranoid ideation conviction rating 80-90%

20 20 Hallucinations Does not recognise voices 2 nd and 3 rd person Derogatory, volume and intrusiveness varies Command – in revengeful mode (rape victim) – Harm self Occur on majority of days Coping – Cannabis and isolation = can cope – Cannabis and going out = sometimes cope – No cannabis and out = cannot cope – Mood relieved by crack cocaine and heroin Voices conviction rating 90%

21 21 Brief analysis of substance misuse PROS Feels chilled - relaxant effect (short lived) Boosts confidence Reduces feelings of rage and anger Enhances music Something to do Relieves low mood CONS Costly >1 ounce cannabis a week (£100+); much as can afford of crack and heroin Conflicts with personal image of self reliance and physical fitness (previously fitness instructor) Feels dependent on it Artificially relieves anxieties Artificially creates euphoria Reduces sleep quality

22 22 Focus on one ‘PRO’ - Chilled Voices less intrusive and voluble Anxiety (autonomic) diminishes – Headaches, physical tension remains quite marked Paranoid ideation - unchanged in conviction & frequency, less intrusive however Feelings of rage and anger about family less dominant Objective – emphasise the self medication aspect that then reappears in a ‘con’

23 23 Focus on one ‘CON’ – artificially relieves anxiety and improves mood Demonstrates insight of this maladaptive coping strategy (i.e. Short lived) – “there must be a way I can cope, without drugs, like other people do” led to “I used to manage OK” Connects ‘artificial’ psychoactive effect to her personal image belief of health and self reliance – “I feel less depressed when I’m stoned but it’s wrong to rely on it….and that thought makes me feel low…especially when I’m no longer stoned” Both statements demonstrate motivation to change

24 24 Motivation Necessary prior to cognitive behavioural work – Shared goals and agenda Building motivation through motivational interviewing – Strategies such as decisional balance matrix (pros & cons) – Principles of empathy, rolling with resistance, developing discrepancies, supporting self-efficacy Preparation for cognitive work can start at Contemplative stage of motivation

25 25 MI Preparation contemplation preparation action maintenance relapse pre-contemplation established change

26 26 Decisional Balance Sheet Good things Not so Good Not ChangeChange

27 27 Importance and confidence Confidence Importance Readiness to change 0 10

28 28 Preparation - Cognitive Model View of past View of immediate life situation View of future Self-view Affect CognitionsBehaviour

29 29 Beliefs that predispose to change My current behaviour is ‘bad’ for me (importance) I would be better off if I changed (importance) If I try to change I can be successful (confidence) This is a good time to do it (readiness)

30 30 Trigger/High Risk Situation (out, paranoid feelings anxiety low mood) Beliefs (cannabis is good for me, need it to get going, relieve tension/ anger, craving) Auto Thoughts (What the hell! My life has turned out bad) Cravings / positive anticipation (physical and psychological – anticipated positive effect) Permissive thoughts (I deserve not to suffer this tension, it’s not my fault) Urge / Focus on Action (Score, roll joint - relief begins) Use / lapse / relapse (relief obtained) Sequalae (dissonance- feel bad / weakened resolve; relief short-lived) Susceptibility to Triggers Coming up with a ‘Relapse Cycle’ or case formulation

31 31 Beliefs about substances that contribute to cravings and urges BELIEFPROCESSREPLACEMENT BELIEFS MAINTAINING STRATEGIES AFFIRMED REPLACEMENT BELIEFS Anticipatory Expectations (relief- orientated) Permissive Catastrophic Assess, examine and test out belief (Socratic questioning, guided discovery) Not as good as expected Temporary relief only I used to do good satisfying things so I could do them again It’s not my fault but I can do something else It can improve, this is a lapse not a relapse ‘Cons’ flashcard Success flashcard Activity schedule Supporters / sponsors Imagery techniques I can get relief elsewhere / other ways I can do things OK I don’t need it. Document and reference (flash card, anchor memories)

32 32 Trigger/High Risk Situation (out, paranoid feelings anxiety low mood) Beliefs (good/bad for me, need a joint to get going, relieve tension/ anger, craving) Auto Thoughts (What the hell! My life has turned out bad) Cravings (physical and psychological – anticipated positive effect) Permissive thoughts (I deserve not to suffer this tension, it’s not my fault) Urge / Focus on Action (Score, roll joint - relief begins) Use / lapse / relapse (relief obtained) Sequalae/ catastrophic (dissonance- eel bad / weakened resolve, it’s getting worse) Susceptibility to Triggers Red – Cognitive Green - behavioural Relapse Cycle: Opportunities for Intervention

33 33 Considering and selecting symptoms MoodAntidepressants, CBT, Counselling, psychotherpay Cognitive / thinking Examine (and test) cognitive errors such as personalisation, over generalisation, dichotomous thinking, and harsh self-criticism. Examine, (test) and reframe core beliefs such as I’m helpless, nothing works for me, I’m alone, I’m stupid, life is empty, it’s good for me, I need it to get going. Introduce replacement beliefs such as relief is temporary, I used to manage OK without it Reattribution of responsibility (extrinsic factors to internal factors – empowerment / self-efficacy) Behavioural Activity schedule, relapse prevention suicide prevention, social skills- assertiveness, vocational, employment, ‘cons’/ success flash cards, PMR relaxation Physiological Sleep hygiene, hypnotics, activities, anxiety management Motivational Pros and cons of current use / behaviour (wishes to escape - suicide / drugs), importance & confidence

34 34 Imagery techniques STOP (spoken volubly) and MIND’S EYE visual imagery of stop sign, police officer, relative, sponsor IMAGE REPLACEMENT by empty wallet, hangover, physical injury, poor health, victim

35 35 Exercise (optional) Groups of 4-6 people Identify an existing client Or Create your groups own client Create a Relapse Cycle Highlight potential intervention opportunities within the relapse cycle Cognitive / behavioural / social / pharmacological Make a few notes for a brief feedback (if we’ve time!)

36 36 A – FRAMES Assessment (thorough but not at expense of engagement) Feedback (accurate and specific to assessment) Responsibility (clients but may need graduating) Advice (accurate, evidenced & neutral) Menu (of options) Empathy (avoid confrontation and resistance) Self – efficacy

37 37 Conclusion Initial Focus on Engagement Thorough Assessment – Symptom selection – Intervention choice Motivational Interviewing – Preparation Cognitive-Behavioural Techniques - Action Timing, perseverance and optimism

38 38 Did it work?

39 39 There is an alternative! Russians thrash drug takers to stop addiction “On the first day we beat them with belts until their buttocks turn blue. Every week we have to buy a new belt because they go too soft, but we have been impressed with the quality of Gucci belts. Drug addicts are animals who have lost all sense of values. This way, the next time they think about getting a fix they remember the pain of the thrashing rather than the rush of the drugs. It's very effective. You cannot solve this with mild manners - you need tough measures” City Without Drugs - Igor Varov Reported by Drugscope

40 Dual diagnosis beyond c 16 HONOS substance misuse subscale rating is conventionally substance treatment orientated SMI & SM often need designating to 16 by care cluster rater No care cluster for non-psychotic DD (as yet)

41 Honos Substance Misuse Subscale Item Scoring: 0= None: No problem of this kind during the period rated. 1= Minor problem: Some over indulgence, but within social norm. 2= Mild problem; Loss of control of drinking or drug taking, but not seriously addicted. 3= Moderate problem: Marked cravings or dependence on alcohol or drugs with frequent loss of control; risk taking under the influence. 4= Severe problems: Incapacitated by alcohol/drug problems.

42 End Any comments Thank you

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