L4: Comorbidity & Role of Family and Friends

Question 1

Why does substance abuse often co-occur with other disorders? 4 explanatory models

Answer 1

• 3rd factor hypothesis: no direct relatnship but SUD and other MD share same cause (third factor, for ex genetics or environmental risk factor)
• self medication hypothesis: mental disorder -> excessive use of a substance to control emotional pain (spoiler alert, they only make each other worse)
• high risk-hypothesis: excessive use of substance -> behaviour that increases risk for, for ex; trauma exposure -> mental disorder
• susceptibility hypothesis: excessive use of substance -> neurobio changes introduced by substance makes more susceptible to develop ex PTSD after trauma -> mental disorder
• bidirectional hypothesis: SUD and other MD may influence each other / have bidirectional interrelations

Question 2

What are some important mechanisms that play a role in both SUD & MDs?

Answer 2

• genetic & environmental factors -> neurobio mechanisms in SUD & MDs
• neuronal & molecular mechanisms: monoaminergic neurotransmission systems, hypothalamus-pituitary axis (HHA), immunological system, neurotrophic factors (e.g., BDNF), endocannabinoid system, and systems regulating food intake, metabolism, and circadian rhythms
• reward circuits

Question 3

What are the psych symptoms induced by alcohol & alcohol withdrawal?

Answer 3

alcohol: depressed mood, fear, confusion, mood swings, sleep problems
wihdrawal: 0-12h: general bad/sick feeling, headache, nausea, vomiting, light shaking, fear, not eating
12-36h: insomnia, restlessness, agitation, tremors, sweating, palpitations
48h: withdrawal feeling/delirium, tremor, sweating, agitation, slight fever, hypertension

Question 4

What are the psych symptoms induced by weed & weed withdrawal?

Answer 4

cannabis: concentration issues, memory impairment, fear, suspicion/paranoia/psychosis
withdrawal: insomnia, depressed mood, agitation

Question 5

What are the psych symptoms induced by cocaine?

Answer 5

lack of energy, depressed mood, insomnia, fear and panic, suspicion/paranoia

Question 6

Why is it important for diagnosis & treatment to consider comorbidity?

Answer 6

• more severe symptoms
• lower treatment compliance
• higher drop out
• worse treatment outcome
• higher prob of relapse

Question 7

What are the common co-morbid substance abuse disorders?

Answer 7

mood disorders, anxiety disorders, personality disorder (BPD, Anti social), ADHD, psychotic symptoms or delirium (in intoxication or withdrawal)

Question 8

Why do close relatives of substance abusers also benefit from counseling?

Answer 8

becuase they struggle with trying to help their loved one which can lead to sadness, depression, anger, confusion, shame, guilt, frustration, and feelings of powerlessness and insecurity
can also encounter conflicts, domestic violence, financial problems, disrupted relation w their kids, relationship & sex issues

Question 9

How do close relatives contribute to successful treatment of addiction?

Answer 9

can contribute to positive change by playing role in getting their loved the treatment they need & play role in CBT treatment itself
can also play negative role by facilitating substance abuse

Question 10

What are different interventions in which close relatives contribute to the treatment of substance abuse?

Answer 10

• Ai-ANon
• Johnson intervention
• CRAFT
• BCT

Question 11

What is Ai-Anon?

Answer 11

based on 12 steps of AA. helps relative accept they are powerless & help them to “detach w love” from the addict. they shouldnt try to influence addicts behaviour

Question 12

What is Johnson intervention?

Answer 12

aka confrontational intervention
addict unexpectedly confronted by relatives about negative consequences of use
this “breaking through resistance” is seen as last chance to rescue addict in life or death situation
relatively little evidence for it

Question 13

What is CRAFT?

Answer 13

Community Reinforcement and Family Training
- protocolized treatment where relatives, supported by practitioner, adjust their behaviour to motivate patient to start treatment so QOL of everyone can improve
- based on CBT & MI
- create FA of substance abuse & subsequent strategies to discourage the behaviour
- emergency plan for violence
- communication training
- positive reiforcement of desired behaviour (contingency management) by close relatives
- not rewarding unwanted behaviour & allowing negative reinforcement
- improving quality of your own life
- proposing to start treatment

Question 14

How does CRAFT perform in patient engagment compared to Ai-Anon and Johnson intervention?

Answer 14

3x more engagment than Aianon
2x more engagment than Johnson
overall better results

Question 15

What is BCT & its aims?

Answer 15

Behavioural Couple Therapy
- compared to CRAFt, here relative is actively involved in treatment of the addict
aims:
- teach the couple effective ways to cope with substance ‐ related situations
- teach the partner to support/reinforce behavior change and sobriety
- improve relationship satisfaction and reduce stress (in order to prevent relapse), by enhancing positive, rewarding exchanges between partners, and boosting healthy communication patterns and problem-solving skills.

Question 16

What is the effectiveness of BCT?

Answer 16

• large effect on relationship satisfaction, but only a weak-moderate effect on substance abuse
• but RS seems to be a protective factor for relapse

Question 17

When is BCT recommended?

Answer 17

Because BCT is expensive and intensive, it is recommended only when individual therapy is ineffective; when there are severe triggering relationship issues; only when the partner is willing to be involved in treatment.

Question 18

What are the specific interventions in BCT?

Answer 18

• Sobriety contract
• Behavioral contract to us
• Relationship aspects as part of the functional analysis
• Shifting negative selective attention in the relationship
• Increase in positive activities
• Communication training
• Discuss relational problems
• Fallback and emergency plan

Question 19

How should the order of diagnosisng & treating substance abuse and comorbid disorders go?

Answer 19

• if psych complaints can be caused or exacerbated by substance abuse: address substance abuse first, then diagnosis & treatment of comorbid disorder
• PRISM interview & general differential characteristics can help distinguish independent MD from substance induced MD
• both should be addressed

Question 20

How should anxiety disorders comorbid w SUD be diagnosed?

Answer 20

• much overlap in symptoms between diagnoses
• preferable to wait 2-3w before diagnosis, during which time screening can take place (exceptions: GAD, SAD, OCD, phobia, PTSD)

Question 21

How does the relationship between anxiety disorders and SUd work?

Answer 21

• anxiety disorders pathopsychology may involve impaired neurotransmisson of serotonin & GABA, which alcohol affects, potentially exacerbating anxiety symptoms
• anxiety symptoms can be result of use: intoxication & withdrawal
• or substance use can be caused by anxiety
• anxiety can maintain SUD & cause relapse

Question 22

How can co-morbid anxiety & substance use be prevented?

Answer 22

• prevention programs targeting young and/or anxious ppl (hihglight role of alcohol problems in predicting addiction)

Question 23

How can comorbid anxiety & substance use be treated?

Answer 23

• some anxiety symptoms may alleviate post detox (& return w relapse)
• exposure therapy & CBT can help w the anxiety
• pharmacological treatments like benzos & antidepressants can also help anxiety
• integrated treatments less studied

Question 24

Define substance-induced Mood Disorder

Answer 24

when episode occurs entirely during period of heavy substance use or within first 4w after cessation of use, and the substance used is relevant to the disorder and the symptoms are greater than the expected effects of intoxication and/or withdrawal

Question 25

Define MD independent from substance

Answer 25

when symptoms are substantially in excess of what would be expected given the type amount duration of substance used; onset of symptoms precedes onset of substance use; or symptoms persist for a period of time after the cessation of intoxication or withdrawal

Question 26

What are the 2 major indictors of substance induced mood disorder?

Answer 26

- emergence of mood symptoms during an escalation of consumption - emergence of mood symptoms during a significant drop in consumption

Question 27

What are the challenges in identifying mood disorder in addictss?

Answer 27

- Substance use effects mimic MD symptoms, complicating differentiation between primary MD and substance-induced symptoms - Psychiatric diagnoses like MD lack well-known pathophysiology & bio markers, leading to reliance on operational diagnostic criteria like DSM and ICD.

Question 28

What are the 5 major indicators of independent mood disorder?

Answer 28

- emergence of mood symptoms during a period of stable or occasional consumpton - persistence of mood symptoms after 1w of withdrawal - history of mood disorder in absence of substance use - family history of mood disorder - history of good response to anti mood disorder treatments in the past (like antidepressants)

Question 29

Is the prevalence of induced MD or independent MD higher?

Answer 29

higher prevalence of independent MD - often ppl initially diagnosed w induced MD are later reclassified as having independent MD, indicating transition over time (intially the severe drug dependence symptoms presence makes an induced diagnosis more likely, or that the substance use masks the MD symptoms etc) - ppl w MD have higher risk of developing SUD and vice versa

Question 30

How can comorbid Mood Disorder with SUds be treated pharmacologically?

Answer 30

- some antidepressants improve comorbid depression w alcohol dpeendence but not depression concurrent w cocaine/opiate dependence - through this the substance use may improve when depressive symptoms improve, but antidepresssants dont directly improve substance use - interactions between antidepressants & drugs & comorbid physiacal illnesses can be toxic so need to watch out for this - watch out for antidepressant dependence - combined treatment of sertraline for depression and naltrexone for alcohol dependence has been effective in reducing depressive symptoms and excessive drinking simultaneously.

Question 31

How can comorbid addiction & depression be treated?

Answer 31

- in 80% of clients, symptoms of depression dissapear after quitting alcohol - timeline can be helpful since clients often see their substance use as self medication

Question 32

How can comorbid substance use & PTSD be treated?

Answer 32

- high prevalence - abstinence not required for PTSD diagnosis - intergrated treatment! - exposure is possible

Question 33

What are 5 reasons why substance use & PTSD co-occur?

Answer 33

1. At-risk hypothesis: substance use increases risk of trauma (e.g., because of the external environment or more risky behavior) 2. Self-medication hypothesis: more substance use to cope with PTSD > most supporting evidence 3. No habituation trauma due to being under the influence (you will get less triggered by things around you if ur drunk/high) 4. Substance use triggers symptoms 5. Underlying causal factor (e.g., genetic predisposition / vulnerability)

Question 34

How should comorbid ADHD & SUD be treated?

Answer 34

- meds less successful so CBT preferred - Diagnosing ADHD while people are still using alcohol is challenging because symptoms overlap with effects of alcohol and withdrawal. Anamnestic information from parent is important.

Question 35

How should comorbid bipolar & SUD be treated?

Answer 35

challenging but little research so follow regular guidelines

Question 36

How should comorbid PD & SUD be treated?

Answer 36

- Screening only indicated if suicidality or selfharm interferes with treatment

Question 37

What are the general diagnostic guidelines for comorbid mental disorders with

Answer 37

- Screening at intake: PTSD, ADHD, anxiety and mood disorders using short questionnaires - GGZ: 2-3w of alcohol abstinence for diagnosis of other syndrom disorders w structured interview - No general guidelines for other substances. Suggestion is half-life of the drug - Exceptions to this are social anxiety, OCD, specific phobia, PTSD, and GAD, where longer absitnence is needed for diagnosis - If no abstinence: try to draw up a timeline with substance use and complaints> draw up hypotheses - Consider clinical admission if abstinence is difficult to achieve

Question 38

What is the general advice for dual disorder treatment?

Answer 38

- addiction has to be treated - integrated treatment - for co morbid disorders with no integrated treatment available, follow the normal treatment guidelines for this disorder parralel to the addiction treatment - psycho education regarding relationship between use & psych symptoms - functional analysis - consider risk situations for substance use - treatment at one location consultation

Question 39

What makes comorbid treatment so difficult?

Answer 39

- ppl often either underestimate substance use or underestimate psych symptoms based on institution - Due to waiting lists / relapse, clients are often sent back and forth between psychiatric and addiction services and fail to receive proper diagnosis/treatment