Comorbidity or Co-Occurring Disorders
Secondary Psychopathology Model
*Mental illness is secondary to substance use. - Substance --> Mental illness/Psychopathology - Substances Constrict - Substance use deprives persons of important and beneficial reinforcers in their lives
Four Explanatory Models of Comorbidity
Common Factor Model (Correlation Liability): Common Factor --> Psychiatric Disorder --> Substance Use Disorder Secondary Substance Use Disorder Model: Psychiatric Disorder --> Substance Use Disorder Secondary Psychopathology Model: Substance Use Disorder --> Psychiatric Disorder Bi-Directional Model (Reciprocal): Psychiatric Disorder <--> Substance Use Disorder
Treatment
Mental Health Tx: • view drugs/pharmacology as helpful - psychotropic medications prescribed to relieve psychiatric distress • abstinence = pre-condition for tx • client self-motivation necessary Substance Use Tx: •has relied predominantly on peer counseling •views drugs of any sort as dangerous •abstinence = outcome of tx
Assume the Rule
• "Co-occurrence is the rule rather than the exception in psychiatric inpatient and substance abuse settings" • Substantial number of all clients have co-morbid disorders: - in MH tx setting, 40-60% also have a SUD - in AOD tx setting, 60-80% also have MH disorder *65% of adolescents psychiatric inpatients have SUD
Difficulty Diagnosing CODs
• Are client's presenting signs and symptoms manifestations of an underlying or co-occurring psychiatric disorder, or are they consequences of drug intoxication and/or withdrawal? • Importance of maintained sobriety to make any distinctions • often, time needed for client to be able to distinguish psychiatric symptoms from drug-related symptoms - anxiety separate from withdrawal? - paranoia or hallucinations separate from intoxication? • psychiatric history before onset of regular use - what was person like before he/she started using regularly? - use of timeline - importance of collateral information from parents, siblings • meaning substance has/had for client • client's sense of "others inside" - mental illness and addiction = distinct entity, separate from me, not me
Secondary Psychosocial Effects Model
• Cognitive, economic, educational, vocational, and other consequences of mental illness increase propensity of substance misuse • Consequences of mental illness predispose person into relationships and living conditions "ripe" with substance use - symptoms or repercussions of mental illness "set me up" for substance use - binge eating disorder in bulimia typically precedes onset of SUD
Concerns about Self-medication Hypothesis
• Draws attention away from addiction - focus is on psychiatric disorder - minimizes (1) inherent addictive potential of substances of abuse and (2) complexity of addiction • Perpetuates substance misuse
Many Names
• Dual diagnosis • Co-occurring disorders • Comorbid disorders or comorbidity
Supersensitivity Model
• Greater sensitivity to effects of substances, particularly for persons with SPMI * Low doses or quantities trigger symptoms - Few clients with SPMI able to sustain moderate substance use over time • Only < 5% of persons with schizophrenia able to sustain symptom-free drinking 7 years after MH tx without experiencing negative consequences (Drake & Wallach, 1993) * Abstinence may therefore need to be goal
Characteristics of Persons with CODs
• Younger and more often male - although women with SUD at high risk for CODs • Less able to manage their lives in community (e.g., obtaining regular meals, maintaining stable housing, managing finances, participating in regular activities) • Exhibit greater hostility, suicidality, and speech disorganization • History of violent behavior • Poorer medication compliance • Twice as likely to be hospitalized • More likely to be poly-drug users
Addictive and Other Mental Disorders
• common, occur with high frequency in general population and, more so, in clinical populations • globally, mental or psychiatric disorders (primarily mood and anxiety) seen in: -30-40% of persons with alcohol disorders -40-53% of persons misusing other substances Sellman (2009, p. 8) estimates 75-90% *Persons with CODs = "System Mis-fits"
Common Problems among Persons with CODs
• depression and suicidal behavior - esp. with crack cocaine • poor tx compliance - primarily those who recently completed psychiatric hospitalization - diminished ability to comply with long-term tx • rehospitalization - strong tendency to present in crisis • persistent symptoms of illness - depression, anxiety, hallucinations, delusions • increased vulnerability to relapse - may often precede psychiatric relapse • psychosocial chaos - impairment in all areas of functioning: high risk sexual behaviors, involvement in child welfare agencies, legal difficulties, inability to manage finances, poverty - 36.7% of homeless women and 32.2% of homeless men estimated to have CODs in 2000 • incarceration • increased vulnerability to HIV infection • lower satisfaction with familial relationships • higher service utilization and costs
Self-Medication Hypothesis
•Analogy of "playing doctor on self" •Assumptions: -pre-existing (and independent) psychiatric disorder -use of substance(s) to alleviate symptoms of psychiatric disorder, or negative side-effects of psychotropic medications -intentional (not random) use of a specific drug Example: - For persons with schizophrenia, may have biological or neurochemical basis -Negative symptoms of schizophrenia may be due to dopamine activity and certain substances (e.g., cocaine) dopamine levels -Some evidence that those with schizophrenia preferentially abuse stimulants
Common Factor Model (Correlation Liability)
•Comorbidity result of shared risk factors (particularly salient in formative years) •One or more factors independently ↑ risk of both substance abuse and psychiatric illness •There are risk factors common to/shared by problematic substance use and mental illness -Trigger, contribute to both (overlapping) conditions -Risk factor(s) not preferential to one condition -Individual with risk factor(s) susceptible to both SUDs and mental illness Prominent Common Factors: •Family hx (parental psychopathology, parental substance use; genetic factors = disorder specific) •Individual personality variables (sensation seeking, risk taking, impulsive behavior, conduct and ASP disorders) •Environmental factors (poverty, low SES, availability of alcohol/drugs in home, poor parental support, poor parental supervision or neglect, parental separation or divorce, affiliation with deviant peers) •Traumatic events (physical/sexual abuse, early loss) •Cognitive impairment
Bidirectional Model
•Different factors related to mental illness AND SUDs contribute to onset and maintenance of CODs •Symptoms of one disorder trigger onset of symptoms in other disorder while maintaining or exacerbating symptoms of initial disorder •Mutual influence; interactive effects •Cyclical or reciprocal causation and maintenance • Less concerned with sequencing of conditions (i.e., chicken-or-egg question) • Importance of multiple risk factors in immediate social environment (e.g., negative peer influences, employment problems) that reinforce one another over time • Recovery not linear
Secondary Substance Use Disorder Model
•Indication that MH problems often precede problematic substance use among youth •Lifetime co-occurring disorders: *83% reported MH disorder prior to SUD -13% reported SUD prior to MH disorder -4% reported onset occurring at same time •12-month co-occurrence rates: *89% report MH disorder prior to SUD -10% reported SUD prior to MH disorder -1% reported onset occurring at same time
Secondary SUDs Models
•Self-medication Hypothesis •Alleviation-of-Dysphoria Hypothesis —General dysphoria (not specific symptoms) = motivation for substance use •Supersensitivity Model •Secondary Psychosocial Effects Model —Cognitive, economic, educational, vocational, and other consequences of mental illness increase propensity of substance misuse —Consequences of mental illness predispose person into relationships and living conditions "ripe" with substance use
