2. Evaluating & Managing The Dual Diagnosis Patient
Peter A. DeMaria, Jr.., M.D., FASAM
Coordinator of Psychiatric Services
Tuttleman Counseling Services
Clinical Associate Professor of Psychiatry & Behavioral Sciences
Department of Psychiatry & Behavioral Sciences
Temple University School of Medicine
Philadelphia, Pennsylvania

3. Case Study A
Anne is a 19 year old student who tells you that she has been diagnosed with ADHD, anorexia nervosa, depression, borderline personality disorder and alcoholism. She is prescribed methylphenidate (Concerta), citalopram (Celexa), quetiapine (Seroquel) and alprazolam (Xanax). She recently had a relationship break-up. She feels her depression is getting worse and she has started to drink again. She appears of average height and weight.

4. Case Study B
Brian is a 20 year old student who complains of problems with concentration and focus. He finds that he forgets to do important things; this forgetfulness has caused problems with his schoolwork and in his relationship with his GF. He has a well documented ADHD history and would like to restart his stimulant. He reports that he likes to party with his friends on the weekends and smokes MJ during the week to help him relax and sleep.

5. Case Study C
Bill is a 21 year old student who presents stating that he has mood swings and can’t sleep. He has a history of binge alcohol and cocaine use, but says he hasn’t had any cocaine in a month.

6. Presenting Psychiatric Symptoms
Dual Diagnosis
6/4/2010
Presenting Psychiatric Symptoms
Anxiety
Depression
Insomnia
Psychotic symptoms
Disruptive behavior
Peter A. DeMaria, Jr., M.D., FASAM

7. Causes of Psychiatric Symptoms
Dual Diagnosis
6/4/2010
Causes of Psychiatric Symptoms
Drug intoxication or withdrawal states
Medical illness
Psychiatric comorbidity
Peter A. DeMaria, Jr., M.D., FASAM

8. The Challenge
Mental
Illness
Dual
Diagnosis
Substance Use
Disorder

9. Definition of Addictive Disease
Addiction is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or episodic impaired control over drinking or drug use, preoccupation with alcohol or drugs, use of alcohol or drugs despite adverse consequences, and distortion in thinking, most notably denial.
(Adapted from the NCADD and ASAM Definition of Alcoholism.)

10. Chronic Disease Model Prototypes: CAD, HTN, DM
Development and course reflect an interplay of genetic vulnerability, pathophysiology, and personal behaviors
Treatment focuses on management not cure
Goals include highest quality of life
Patient must take an active role in treatment
Compliance is frequently an issue

11. Substance Use Is a Spectrum Disorder
Abstinence
Experimentation
Substance abuse
Substance dependence

12. Lifetime Prevalence of Comorbidity - ECA Date
Mental Disorders, 22.5%
Comorbidity = 29%
Alcohol = 22%
Other drug = 15%
Alcohol Disorder, 13.5%
Comorbidity = 45%
Psychiatric - 37%
Other drug = 22%
Other Drug Disorder = 6.1%
Comorbidity = 72%
Psychiatric = 53%
Alcohol = 47%
JAMA 264(19): ,1990

13. Epidemiology of Dual Diagnosis
ECA Study: Alcoholics have x higher incidence of depression than general population
Alcoholics:
At intake 70% have moderate to severe depression
4 - 6 weeks after detox 10-20% had major depression
Psychiatric inpatients at McLean Hospital: 60% of males and 40% of females met criteria for alcohol or drug abuse or dependence

14. Epidemiology of Dual Diagnosis
Cocaine addicts at McLean Hospital: 27% had affective illness.
Opiate addicts: 54% had lifetime incidence and 24% had current episode of major depression.
15.2% of respondents in the NCS who had ADHD met criteria for any substance use disorder (3 x the rate of respondents without ADHD).

15. The Biopsychosocial Spiritual Orientation
Biological
Spiritual
Social
Psychological

16. The Biopsychosocial Spiritual Orientation
Biological
Genetics
Health issues
Brain chemistry
Social
Living unit
Relationships
Work/school
Cultural factors
Spiritual
Organizing principles
Morals/ethics
Psychological
Self esteem
Identity
Object relations
Drives/defenses/
conflicts
Developmental history
Trauma/abuse
Personality traits
Relationships

17. “Dual diagnosis is an expectation, not an exception.”
-Dr. Kenneth Minkoff

18. The Four Quadrant Model for Co-Occurring Disorders
Both High Severity
Mental Illness
Low Severity
Substance Use Disorder
High Severity
Both Low Severity
A guide to treatment planning.

19. Disorder Parallels Addiction Major Mental Illness A biological illness
Heredity (in part)
Chronic disease
Incurable
Leads to lack of control of behavior and emotions
Positive & negative symptoms

20. Disorder Parallels Addiction Major Mental Illness
Affects the whole family
Progression of the disease without treatment
Symptoms can be controlled with proper treatment
Disease of denial
Facing the disease can lead to depression & despair

21. Disorder Parallels Addiction Major Mental Illness
Disease is often seen as a “moral issue” due to personal weakness rather than having biological causes
Feelings of guilt and failure
Feelings of shame and stigma
Physical, mental, & spiritual disease

22. Screening-Assessment-Treatment
High index of suspicion
Screen everyone; revisit regularly
Assess which Stage of Change
Engage in treatment
Use Motivational Interviewing techniques
Use behavioral/contingency contacts
Involve others
Consult/Refer

23. Stages of Change Precontemplation Contemplation Preparation Action
Maintenance

24. Differentiating Substance Related Disorders from Psychiatric Disorders
Relationship of symptoms to drug use
Which came first?
Presence of symptoms during periods of sobriety
Past treatment history
Atypical presentation
Poor or unpredictable response to treatment
Family history-psychiatric or addiction
Look for common co-morbidities:
Bipolar disorder and alcoholism
ADHD and substance abuse
Cluster B personality traits/disorder

25. General Approach to the Dual Diagnosis Patient
Comprehensive biopsychosocial spiritual assessment.
Engage patient in treatment and develop a therapeutic relationship.
Develop a treatment plan
Addressing both psychiatric & addiction issues
Assess response
Adjust treatment plan

26. Treatment Planning Treatment planning must be individualized.
The treatment plan must follow a careful assessment.
The treatment plan is not static, it is dynamic and changes as the providers learns more and the patient changes with interventions.
Develop a treatment team utilizing the expertise in other clinicians.
Ensure regular and thorough communication between all treatment team members.

27. Possible Treatment Modalities
Individual counseling/therapy (psychiatric/addiction)
Group counseling/therapy (psychiatric/addiction)
Self-help (12 step) programs
Behavioral/contingency management
Couple’s Therapy
Family therapy
Disability Resources & Services Involvement
IOP/Partial hospitalization
Inpatient psychiatric (dual diagnosis) hospitalization
Psychotropic medication (psychiatric/addiction)

28. Issues Specific to College MH Practice
Hospitalization necessary/indicated?
Treat in-house or refer out?
Is drug screening available?
Must the student be clean for everything?
If not, what is acceptable?
What support is available on campus?

29. Pharmacotherapy of Addictive Disorders
Detoxification
Aversive agents
Disulfiram (Antabuse)
Anti-craving Agents
Naltrexone (ReVia, Vivitrol)
Acamprosate (Campral)
Bupropion (Wellbutrin, Zyban)
Varenicline (Chantix)

30. Pharmacotherapy of Addictive Disorders
Maintenance pharmacotherapy
Nicotine replacement therapy (NRT)
Patch, gum, inhaler, lozenge
Opioid maintenance pharmacotherapy
Methadone
Buprenorphine (Subutex/Suboxone)

31. General Approach to Psychopharmacology
Use biopsychosocial spiritual model
Avoid addictive substances (e.g. BZ)
Treat psychiatric condition if it prevents engagement in addiction treatment.
Avoid making psychiatric diagnosis and initiating medication until 2-4 weeks into abstinence from substances.
Less is better

33. Case Study A
Anne is a 19 year old student who tells you that she has been diagnosed with ADHD, anorexia nervosa, depression, borderline personality disorder and alcoholism. She is prescribed methylphenidate (Concerta), citalopram (Celexa), quetiapine (Seroquel) and alprazolam (Xanax). She recently had a relationship break-up. She feels her depression is getting worse and she has started to drink again. She appears of average height and weight.

34. Case Study B
Brian is a 20 year old student who complains of problems with concentration and focus. He finds that he forgets to do important things; this forgetfulness has caused problems with his schoolwork and in his relationship with his GF. He has a well documented ADHD history and would like to restart his stimulant. He reports that he likes to party with his friends on the weekends and smokes MJ during the week to help him relax and sleep.

35. Case Study C
Bill is a 21 year old student who presents stating that he has mood swings and can’t sleep. He has a history of binge alcohol and cocaine use, but says he hasn’t had any cocaine in a month.