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Treatment of Persons with Co-Occurring Disorders
Based on SAMHSA TIP 42 Part 8
Host: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review

~ A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues
~ Cross-Cutting Issues
~ Personality Disorders
~ Mood Disorders and Anxiety Disorders
~ Schizophrenia and Other Psychotic Disorders
~ Attention Deficit/Hyperactivity Disorder (AD/HD)
~ Posttraumatic Stress Disorder (PTSD)
~ Eating Disorders
~ Pathological Gambling
Cross Cutting Issues
~ Suicidality
~ 25 to 30 percent of ambulatory clients in general medical practices have a diagnosable psychiatric condition, and a further 10 to 15 percent of people suffering from major psychiatric illnesses such as affective disorder, schizophrenia, and alcoholism will end their lives by suicide
~ Suicide is also more likely among those with the personality traits of impulsivity, hopelessness, or cognitive rigidity
~ Abuse of alcohol or drugs is a major risk factor in suicide, both for people with COD and for the general population.
~ Alcohol abuse is associated with 25 to 50 percent of suicides. Between 5 and 27 percent of all deaths of people who abuse alcohol are caused by suicide, with the lifetime risk for suicide among people who abuse alcohol estimated to be 15 percent.
~ There is a particularly strong relationship between substance abuse and suicide among young people.
~ Comorbidity of alcoholism and depression increases suicide risk.
~ The association between alcohol use and suicide also may relate to the capacity of alcohol to remove inhibitions, leading to poor judgment, mood instability, and impulsiveness.
~ Substance intoxication is associated with increased violence, both toward others and self.

~ Screen for suicidal thoughts or plans with anyone who makes suicidal references, appears seriously depressed, or who has a history of suicide attempts. Treat all suicide threats with seriousness.
~ Assess the client's risk of self-harm by asking about what is wrong, why now, whether specific plans have been made to commit suicide, past attempts, current feelings, and protective factors.
~ • Develop a safety and risk management process with the client that involves a commitment on the client's part to follow advice, remove the means to commit suicide (e.g., a gun), and agree to seek help and treatment. Avoid sole reliance on “no suicide contracts.”
~ • Assess the client's risk of harm to others.
~ • Provide availability of contact 24 hours per day until psychiatric referral can be realized. Refer those clients with a serious plan, previous attempt, or serious mental illness for psychiatric intervention or obtain the assistance of a psychiatric consultant for the management of these clients.
~ • Monitor and develop strategies to ensure medication adherence.
~ • Develop long-term recovery plans to treat substance abuse.
~ • Review all such situations with the supervisor and/or treatment team members.
~ • Document thoroughly all client reports and counselor suggestions.

~ What is wrong?
~ Personal narrative about the nature of the problem(s), reasons for suicide and measure of psychological pain and suffering
~ Why now? Elements of the current crisis:
~ Sudden and unacceptable changes in life circumstances; for example, the client just received a serious or terminal diagnosis, relapse, onset of possible symptoms (e.g., sleeplessness)
~ History of real or imagined losses or rejections, possible anniversary phenomena
~ With what? The means of suicide under consideration

~ Where and when? Possible location and timing of a suicide attempt
~ When and with what in the past?
~ Social response to past attempts: Persons who may or may not be helpful in managing the client
~ Why not now?
~ One or more protective factors (reasons for living)
~ Spiritual or religious prohibitions
~ Duties to others or pets and residual “loose ends”
~ Daily smokers and nondaily smokers (11%) had about twice the odds of relapsing to drug use at the end of the three-year period compared to nonsmokers (6.5%)
~ Those who quit smoking during treatment had an 8% relapse rate J Clin Psychiatry 2017;78(2):e152–e160
~ Screen for tobacco use
~ Assessment of tobacco use includes assessing the amount and type of tobacco products used (cigarettes, cigars, chew, snuff, etc.), current motivation to quit, prior quit attempts (what treatment, how long abstinent, and why relapsed), withdrawal symptoms, common triggers, social supports and barriers, and preference for treatment.
~ The current U.S. Clinical Practice Guidelines indicate that all patients trying to quit smoking should use first-line pharmacotherapy, except in cases where there may be contraindications (Fiore 2000).
~ Currently there are six FDA-approved treatments for tobacco dependence treatment: bupropion SR and five Nicotine Replacement Treatments (NRTs): nicotine polacrilex (gum), nicotine transdermal patch, nicotine inhaler, nicotine nasal spray, and nicotine lozenge.
~ When clients with serious mental illnesses attempt to quit smoking, watch for changes in mental status, medication side effects, and the need to lower some psychiatric medication dosages due to tobacco smoke interaction.

Personality Disorders
~ Personality disorders (PDs) are rigid, inflexible, and maladaptive behavior patterns of sufficient severity to cause internal distress or significant impairment in functioning
~ An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
~ Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
~ Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
~ Interpersonal functioning
~ Impulse control

~ May use drugs in a variety of ways and settings.
~ At the beginning of a crisis episode, a client with this disorder might take a drink or a different drug in an attempt to quell the growing sense of tension or loss of control.
~ May well use the same drugs of choice, route of administration, and frequency as the individuals with whom they are interacting.
~ Often use substances in idiosyncratic and unpredictable patterns.
~ Polydrug use is common, which may involve alcohol and other sedative-hypnotics taken for self-medication.
~ 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 on the medication to avoid dangerous withdrawal.

Personality Disorder
~ A pervasive pattern of instability beginning by early adulthood and present in a variety of contexts, as indicated by 5+ of the following:
~ Frantic efforts to avoid real or imagined abandonment.
~ A pattern of unstable and intense interpersonal relationships which alternate between extremes of idealization and devaluation.*
~ Markedly and persistently unstable self-image or sense of self.*
~ Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
~ Recurrent suicidal behavior or threats, or self-mutilating behavior.
~ Affective instability due to a marked reactivity of mood usually lasting a few hours and only rarely more than a few days.*
~ Chronic feelings of emptiness.*
~ Inappropriate, intense anger or difficulty controlling anger*
~ Transient paranoid ideation or severe dissociative symptoms.
Borderline Personality Disorder
~ There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by 3+ of the following:
~ Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
~ Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
~ Impulsivity or failure to plan ahead
~ Irritability and aggressiveness, repeated physical fights or assaults
~ Reckless disregard for safety of self or others
~ Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
~ Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
~ The individual is at least age 18.
~ Conduct Disorder (see APA 2000, p. 98) with onset before age 15.
~ Occurrence is not exclusively during Schizophrenia or a Manic Episode.

~ Use manipulation, intimidation, and violence to control others and to satisfy their own needs.
~ Many people with this disorder use substances in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine.
~ People with this disorder may be excited by the illegal drug culture and may have considerable pride in their ability to thrive in the face of the dangers of that culture.
~ Those who are more effective may limit themselves to exploitative or manipulative behaviors that do not make them as vulnerable to criminal sanctions.

Antisocial Personality Disorder
Mood Disorders
~ About one half of individuals with a substance use disorder have an affective or anxiety disorder at some time in their lives.
~ Women are more likely than men to be clinically depressed and/or to have posttraumatic stress disorder.
~ Older adults may be the group at highest risk for combined mood disorder and substance problems. Episodes of mood disturbance generally increase in frequency with age.
~ Both substance use and discontinuance may be associated with symptoms of depression and anxiety. (PAWS)
~ Medical problems and medications can produce symptoms of anxiety and mood disorders. 25% of individuals who have chronic medical conditions, such as diabetes or stroke, develop major depressive disorder.
Mood Disorders
~ Since mood and anxiety symptoms may result from substance use disorders, not an underlying mental disorder, careful and continuous assessment is essential.
~ Fatigue
~ Sleep disturbance
~ Eating Disturbance
~ Worry
~ Guilt
~ Irritability
~ Difficulty concentrating
~ Apathy/Anhedonia
~ Inattention
~ Fails to pay attention to details
~ Doesn’t seem to listen when spoken to
~ Does not follow through*
~ Difficulty with organization*
~ Easily distracted*
~ Avoids tasks requiring sustained mental effort*
~ Impulsivity
~ Difficulty waiting turn
~ Often interrupts or intrudes on conversations
~ Blurts out answers before question is completed
~ Clarify for the client repeatedly what elements of a question he or she has responded to and what remains to be addressed.
~ Eliminate distracting stimuli from the environment.
~ Use visual aids to convey information.
~ Reduce the time of meetings and length of verbal exchanges.
~ Encourage the client to use tools (e.g., activity journals, written schedules, and “to do” lists) to organize important events and information.
~ Symptoms
~ Re-Experiencing
~ Avoidance
~ Negative thoughts or feelings or emotional numbing (Guilt, blame, depression, anhedonia)
~ Hyperarousal
~ Tips
~ Create emotional and physical safety
~ Explore environmental triggers
~ Empower clients
~ Validate their perceptions
~ Highlight the survival functions of the behaviors
~ Don’t delve into trauma without a safety net

Eating Disorders
~ Approximately 15% of people with a substance abuse issue also have an eating disorder, esp. bulimia
~ Individuals with eating disorders are significantly more likely to use stimulants and significantly less likely to use opioids than other individuals who abuse substances.
~ Many individuals alternate between substance abuse and eating disorders.
~ Alcohol and drugs such as marijuana can disinhibit appetite and increase the risk of binge eating as well as relapse in individuals with bulimia nervosa.
~ Individuals with eating disorders experience craving, tolerance, and withdrawal from drugs associated with purging, such as laxatives and diuretics.
~ The rate of co-occurrence of pathological gambling among people with substance use disorders has been reported as ranging from 9 to 30 percent and the rate of substance abuse among individuals with pathological gambling has been estimated at 25 to 63 percent
~ Someone who is addicted to cocaine may see gambling as a way of getting money to support drug use.
~ A pathological gambler may use cocaine to maintain energy levels and focus during gambling and sell drugs to obtain gambling money.
~ Cocaine may artificially inflate a gambler's sense of certainty of winning and gambling skill, contributing to taking greater gambling risks.
~ Identify ways in which use of addictive substances or addictive activities such as gambling act as mutual triggers
General Interventions: 5 Rs
~ Relevance: Encourage the client to indicate why change could be personally relevant, being as specific as possible.
~ Risks: Motivational information has the greatest impact if it is relevant to a client's disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important client characteristics (e.g., prior quitting experience, personal barriers to cessation).
~ Rewards: Elicit from clients possible benefits of change, with a particular focus on identifying short-term benefits that they will notice immediately.
~ Roadblocks: Help the client to identify barriers or impediments to change. Typical barriers might include withdrawal symptoms, fear of failure, weight gain, lack of support, depression, or enjoyment of the activity.
~ Repetition: The motivational intervention should be repeated every time an unmotivated client visits the clinical setting.
~ People who have failed in previous change attempts should be informed that most people make repeated change attempts before they are successful.
~ Suicidality
~ Nicotine Dependence
~ Personality Disorders
~ Mood Disorders and Anxiety Disorders
~ Schizophrenia and Other Psychotic Disorders
~ Attention Deficit/Hyperactivity Disorder (AD/HD)
~ Posttraumatic Stress Disorder (PTSD)
~ Eating Disorders
~ Pathological Gambling