Continuum of Co-Occurring DisordersContinuum of Co-Occurring Disorders Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC  Executive Director: AllCEUs Counseling CEUs and Specialty Certificates  Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery

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Objectives~ Explore a couple cross cutting issues~ Explore the varying courses of addiction and mental health disorders~ Explore the continuum of addictive behaviors from initiation, intoxication, harmful use, abuse, dependence, withdrawal, craving, relapse and recovery~ Explore the continuum of mental health disorders from mild to severe to recovery, and explore causes of relapse
Mental Health Disorders—Why Do I Care?~ Treating someone with a mental health or personality disorder complicates the picture and increases risk of concurrent disorders~ Addictive~ Mood~ Personality~ People with more chronic or longer standing mental health issues are at a much greater risk for misusing substances or developing addictive disorders.
Mood Disorders—General Information~ Effective differential diagnosis~ Both substance use and discontinuance may be associated with depressive symptoms.~ Acute manic or anxiety symptoms may be induced or mimicked by intoxication with stimulants, steroids, hallucinogens, or polydrug combinations.~ Withdrawal from depressants, opioids, and stimulants invariably includes potent anxiety symptoms. ~ Medical problems and medications can produce symptoms of anxiety and mood disorders. ~ Lookout for substance misuse~ Those with depression favor stimulation and those with anxieties favor sedation, but there appears to be considerable overlap. Mood Disorders Risk Factors~ Genetics: 30-40% of variability~ Environment– Especially multiple adverse childhood experiences, overprotective or disengaged parents ~ Temperamental- Neuroticism/negative affect ~ Moody and to experience such feelings as anxiety, worry, fear, anger, frustration, envy, jealousy, guilt, depressed mood, and loneliness~ Respond worse to stressors and are more likely to interpret ordinary situations as threatening and minor frustrations as hopelessly difficult. ~ Self-conscious and shy~ Have trouble controlling urges and delaying gratificationMood Disorders: Continuum~ Considerations~ Situational~ Episodic with no easily identifiable trigger~ Continuum~ Mild~ Moderate~ Severe~ RemissionMood Disorders Course~ Median Age of Onset~ 13 for social anxiety~ 30 for GAD~ Puberty (10-14) for Major depressive disorder~ Content of anxiety is age appropriate changing over the lifespan~ Depression diagnosis requires 5 of 9 symptoms resulting in 126 possible presentations~ In MDD, the first episode presentation is quite variable with…~ Some never achieving remission of 2 or more months~ Others going years between episodesMood Disorders Course~ Recovery begins within 3 months of onset for 2:5 and within 1 year for 4:5~ The longer the recovery period, the lower the chance of recurrence~ Early onset of persistent depressive disorder is correlated with a higher incidence of developing personality and addictive disorders. (DSM-V)~ Those with chronic episodes or long-standing symptoms have higher risk of developing concurrent mental health and addictive disorders
Mood Disorders Course~ General Course ~ Mood symptoms~ Social problems due to mood symptoms (irritability, fatigue)~ Depression, anxiety, grief about mood symptoms~ Sleep disruption/Exhaustion~ Reduced involvement in important activities (work, family, recreation)~ Withdrawal from social relationships~ Increased mood symptoms

Mood Disorders Course~ General Course (Recovery)~ Desire for help and hope that recovery is possible~ Begins proper self-care (including medical & psychiatric as needed)~ Appreciation of possibilities—What does happiness/recovery look like for you? What would move you from a 1 to a 2?~ Begins getting social support (reduced isolation, encouragement)~ Takes personal inventory to decide what is important (Hope, determination)~ Sets and begins achieving SMART goals (Self-efficacy, resilience)~ Develops distress tolerance and coping skills for current triggers~ Improves interpersonal effectiveness and relationships~ Self-esteem increases~ Increase in emotional and behavioral control
Personality Disorders Risk Factors~ Genetics~ Childhood trauma~ Verbal abuse, especially maternal~ N=793 Those who experienced maternal verbal abuse during childhood were more than three times as likely to develop PDs during adolescence. ~ These associations remained significant after sibling temperament, childhood physical or sexual abuse, neglect, parental education, parental psychopathology, and co-occurring psychiatric disorders were controlled statistically. ~ High-reactivity /Emotional Dysregulation~ Peers~ Lack of secure attachment figuresPersonality Disorders~ First manifest in adolescence~ Adolescents are expected to engage in more independent emotion regulation and self-control strategies, deficits in self-regulatory skills become more apparent~ High rate of concurrent comorbid psychiatric disorders and physical health problems~ Multiple presentations~ BPD for example: The presence of any 5 out of the 9 criteria warrants a diagnosis, resulting in 126 possible combinations of symptoms.Personality Disorders~ People with PDs may use drugs in a variety of ways and settings.~ At the beginning of a crisis episode, a client with a PD might take a drink or a different drug in an attempt to quell the growing sense of tension or loss of control.~ People with PDs often use substances in idiosyncratic and unpredictable patterns.~ Polydrug use/polyaddiction is common~ Individuals with PDs often are skilled in seeking multiple sources of medication that they favor, such as benzodiazepines. ~ Once they are prescribed this medication in a mental health system, they may demand to be continued
Addictive Disorders – Why Do I care~ Addictive disorders are strongly correlated with…~ The presence of mood disorders~ The development of mood disorders~ Neurochemical effects~ Physical effects~ Social/environmental effects~ Employment/financial effects~ Relapse or lack of treatment effectiveness for mood disordersAddictive Disorders Risk Factors~ Genetics~ Childhood trauma~ Verbal abuse~ High-reactivity /Emotional Dysregulation~ Peers~ Lack of secure attachment figures~ Early use of substances


Criteria for Substance Use Disorder~ Criteria~ Larger amounts or over a longer period of time than intended~ Unsuccessful efforts to cut down~ Great deal of time spent getting, using, recovering from use~ Craving~ Recurrent use resulting in failure to fulfil major role obligations~ Continued use despite recurrent problems caused by or worsened by use~ Important activities are reduced because of use~ Recurrent use in physically hazardous situations (DUI, childcare)~ Continued use despite knowing use is causing problems~ Tolerance (diminished effect)~ Withdrawal
Continuum of SUDs~ Initiation/Intoxication~ Harmful use~ Abuse~ Dependence~ Withdrawal~ Craving~ Relapse ~ RecoveryAddiction Course (Jellinek)~ Occasional use/involvement~ Frequent use for relief/pleasure~ Increases in tolerance~ Superstitious use/involvement~ Increasing physical or psychological dependence~ Feelings of guilt~ Decrease of ability to stop when others do or would~ Promises to stop/change fail~ Reduced self-esteem~ Avoid family and friends~ Unreasonable resentments~ Guilt and shame increase~ Job loss~ Neglect of health~ Physical deterioration~ Impaired thinking~ Increased mood and personality issues~ Obsession with use/involvementAddiction Course: Recovery~ Honest desire for help~ Hope that recovery is possible (No wrong door)~ Begins proper self-care~ Appreciation of possibilities~ Begins getting social support~ Takes personal inventory to decide what is important~ Develops alternate distress tolerance and coping skills for current triggers~ Sets SMART goals~ Self-esteem increases~ Increase in emotional and behavioral control~ Desire to escape goes away~ Employment and finances stabilize
Cross Cutting Issues: Suicidality~ Abuse/Misuse of alcohol or drugs is a major risk factor in suicide~ Alcohol abuse is associated with 25 to 50 percent of suicides. ~ There is a particularly strong relationship between substance abuse and suicide among young people.~ Comorbidity of a substance use disorder and depression increases suicide risk.Cross Cutting Issue: Nicotine Dependence~ 6 FDA-approved treatments for tobacco dependence treatment: bupropion, and 5 Nicotine Replacement Treatments (NRTs)~ Nicotine treatment medications are effective even without counseling, but adding psychosocial treatments enhances outcomes by at least 50 percent.~ Specific coping skills should be addressed to help smokers cope with cravings associated with smoking cues.~ When clients with serious mental illnesses attempt to quit smoking, watch for:~ Changes in mental status / exacerbation of mood disorders~ Medication side effects and interactions~ The need to lower some psychiatric medication dosages due to tobacco smoke interaction
Summary~ Addictions and mental health issues follow a similar course.~ Recovery requires the desire to change and hope that change will occur.~ Mental health clinicians need to be alert to: ~ Misuse of substances or problematic engagement in addictive behaviors~ Exacerbation of mood issues due to use or withdrawal—even during treatment~ Addiction clinicians need to be alert to~ Changes in mental health~ Potential for addiction relapse with mental health relapse