Dual DiagnosisDual Diagnosis

Dr Nikki WoodDr Nikki Wood

Principal Clinical PsychologistPrincipal Clinical Psychologist

Forensic Dual Diagnosis ServiceForensic Dual Diagnosis ServiceJohn Howard CentreJohn Howard Centre

DefinitionsDefinitions

• The term “dual diagnosis” is generally applied to people who have two or more diagnosed disorders

• Combined mental health and substance use problems

• More than “dual problems”- likely to have complex health and social needs

• Wide range of people with varying degrees of need (c.f. individualised treatment)

Severity of problematic

Substance Misuse

e.g. a dependent drinker who experiences increasing anxiety

Severity of Mental Illness

HIGH

e.g. an individual with schizophrenia who misuses cannabis

LOW

e.g. a recreational misuser of ‘dance drugs’ who has begun to struggle with low mood after weekend use

HIGH

e.g. an individual with bipolar disorder whose occasional binge drinking and experimental misuse of other substances destabilises their mental health

LOW

““Mainstreaming”Mainstreaming”

DH (2002) Good Practice Guide:• Doesn’t advocate a separate specialist service for dual

diagnosis• Mental health services should take primary responsibility

for those with serious mental health problems (like schizophrenia) and substance use

• Substance use services should take primary responsibility for those with primary substance problems and common mental health problems (anxiety, depression)

• However mental health and substance use services should work together and support each other

Consequences in dual diagnosisConsequences in dual diagnosis

• Young, single, male, homeless• lower educational and employment attainment• higher rates of relapse • longer inpatient stays (twice as long - Menezes et al,

1996)• non-adherence to medication • higher rates of violence, suicide and self harm• higher likelihood of involvement with the criminal justice

system,

(Drake and Meuser, 2000)

• Poor physical health - higher rates of HIV, Hep B and C, and other substance use related physical problems

• Family problems• Difficulties getting access to appropriate aftercare• High overall service costs• Higher overall risk of untoward incidents (Drake and Meuser, 2000)

Nutt, King &Phillips, (2010) Drug harms in the UK: a Nutt, King &Phillips, (2010) Drug harms in the UK: a multicriterion analysis, Lancet, online 1st November 2010multicriterion analysis, Lancet, online 1st November 2010

Reasons For Drug Use Reasons For Drug Use (in people with mental health problems)(in people with mental health problems)

• Hedonism, escape and fun

• Self medication

• Cravings

• Medicate medication side-effects.

• Peer acceptance/ social factors.

• Boredom.

• Coping with stressful relationships/situations

Self-medicationSelf-medication

• The use of substances to alleviate painful or uncomfortable emotional or physical states.

• Positive and negative symptoms of psychosis (apathy, flattened affect, slowed thoughts)

• Side-effects of medication (EPSE, akathisia, neuroleptic dysphoria)

• General distress as a result of having a chronic illness (boredom, loneliness, distressing symptoms, labelling)

• Although this hypothesis is not fully supported by the research, and could be considered a convenient medical model explanation

Bio-psycho-social model of Bio-psycho-social model of PsychosisPsychosis

• Developing psychosis is a combination of biological, psychological and social factors

• Biological factors include genes and a history of mental illness in the family

• This would lead individuals to be more prone to developing psychotic symptoms at times of stress (stress-vulnerability model)

• Substance use is also likely to affect the brain chemicals of vulnerable people

Zubin & Spring’s Model of the Interaction Between Zubin & Spring’s Model of the Interaction Between Vulnerability & Stressful Events in Triggering an Vulnerability & Stressful Events in Triggering an

Episode of Schizophrenia (1977)Episode of Schizophrenia (1977)

Maximum

Minimum

Low HighVulnerability

Challenging

Events

Well

ill

Threshold

Psychological factorsPsychological factors• Anxiety and depression

• Stress

• Poor coping and social skills

• Difficult early childhood experiences

• Poor self esteem and sense of self

• Unusual perceptual experiences

• Perception of events as personal and traumatic

Social FactorsSocial Factors• Substance use

• Homelessness

• Financial worries and social deprivation

• Work/school problems/family conflict

• Difficult relationships with others

• Isolation –leads to poor reality testing

• Major life events

Drugs and mental health

CannabisCannabis

• Known as skunk, weed, resin, ganja, grass, Known as skunk, weed, resin, ganja, grass, blow, hash, spliff, sensi, sensimilla, smokeblow, hash, spliff, sensi, sensimilla, smoke

• Was reclassified to Class B in January 2009Was reclassified to Class B in January 2009• Is usually smoked with tobacco rolled in a Rizla Is usually smoked with tobacco rolled in a Rizla

paper.paper.• Main active ingredient is Main active ingredient is ∆∆THC THC

(tetrahydrocannabinol)(tetrahydrocannabinol)• Cannabis can cause anxiety, panic attacks, Cannabis can cause anxiety, panic attacks,

paranoia and restlessnessparanoia and restlessness

CannabisCannabis

• People with psychotic symptoms are more than twice as People with psychotic symptoms are more than twice as likely to use cannabis as those withoutlikely to use cannabis as those without

• Why is this? The jury is still out but may be self-Why is this? The jury is still out but may be self-medicating medicating

• However research suggests that cannabis use, However research suggests that cannabis use, especially the use of stronger forms of cannabis such as especially the use of stronger forms of cannabis such as skunk, can increase the likelihood of developing skunk, can increase the likelihood of developing schizophrenia in psychosis-prone individuals schizophrenia in psychosis-prone individuals

• New research has found there is a particular marker New research has found there is a particular marker gene for a negative response gene for a negative response

• Age of first use also a factorAge of first use also a factor

Does cannabis cause sz?Does cannabis cause sz?

• Does cannabis cause schizophrenia?– Childhood use found to double chances of schizophrenia in later

life

– Andreasson et al 1987• The higher the frequency of use prior to age 18 the more

likely to develop schizophrenia

– Arseneault et al 2002• If using by 15 you are 4.7% more likely to develop

schizophrenia• If using by 18 you are 10.3% more likely to develop

schizophrenia

• Semple et al (2005) in their meta-analysis found that early use of cannabis was related to an increased risk of psychosis, and vulnerable groups were those who had used cannabis at a very early age, those who had already experienced psychotic symptoms and those with a genetic risk for developing SZ.

• Vigella (2008) also found that frequency of use was also a factor with daily cannabis use found in 66% of their early onset sample

• Cannabis potency recently confirmed to be a factor (Di Forti et al, 2009; n=280) with skunk increasing the risk of psychosis 6.8 times. Length of use (more than 5 years) and frequency (daily) also found to be factors.

• However Hickman (2009) found that you would need to stop 2,800 heavy male users or more than 5,000 heavy female users to prevent a single case of schizophrenia

CannabisCannabis

• Recent research has found that some chemicals in Recent research has found that some chemicals in cannabis may have antipsychotic and antianxiolytic cannabis may have antipsychotic and antianxiolytic effects effects

- cannabidiol (CBD)- cannabidiol (CBD)• which may explain why some people keep on using it which may explain why some people keep on using it

despite the THC sometimes making other symptoms despite the THC sometimes making other symptoms worse. e.g. paranoiaworse. e.g. paranoia

• Some evidence that there can be paranoia and agitation Some evidence that there can be paranoia and agitation on withdrawal – psychological dependence?on withdrawal – psychological dependence?

• Harm minimisation most helpful, smoke less, and smoke Harm minimisation most helpful, smoke less, and smoke less strong versions e.g. avoid skunk and sensimillaless strong versions e.g. avoid skunk and sensimilla

So cannabis use can contribute to the development of psychosis, especially the use of skunk at an early age

And ongoing and frequent use can make symptoms worse or lead to a relapse

But also used to help with symptoms – paradox!

New research has found there is a particular gene that may in the future mark out who is more vulnerable to psychosis and who will have a negative effect from cannabis

AlcoholAlcohol

• Is a CNS depressantIs a CNS depressant• At low doses has a disinhibiting effectAt low doses has a disinhibiting effect• At higher doses leads to dysphoria/low moodAt higher doses leads to dysphoria/low mood• Depressive effects are transientDepressive effects are transient• Strongly linked with violence and suicideStrongly linked with violence and suicide• Is also a factor in personality disorder and

pathological jealousy• Use common with axis 1 and axis 2 disordersUse common with axis 1 and axis 2 disorders• May be used to manage hyperarousal or agitation May be used to manage hyperarousal or agitation

but also masks symptomsbut also masks symptoms• Also used to cope with physical painAlso used to cope with physical pain

• Withdrawal could lead to increased arousal and exacerbation Withdrawal could lead to increased arousal and exacerbation of symptomsof symptoms

• Used as a means of avoidance –cognitive and emotionalUsed as a means of avoidance –cognitive and emotional• May relieve feelings of isolation, loneliness, emptiness and May relieve feelings of isolation, loneliness, emptiness and

anxietyanxiety• Prolonged excessive use can lead to brain and liver damage Prolonged excessive use can lead to brain and liver damage

and memory problemsand memory problems• Also linked with heart disease and cancer.Also linked with heart disease and cancer.• Withdrawal/hangover can lead to anxietyWithdrawal/hangover can lead to anxiety• May be used to cope with anxiety, PTSD symptoms, sleep May be used to cope with anxiety, PTSD symptoms, sleep

problems, social phobia and depressionproblems, social phobia and depression• Commonly used with other substancesCommonly used with other substances

Cocaine/crackCocaine/crack

• Is a stimulantIs a stimulant• Coke, charlie, snow, freebaseCoke, charlie, snow, freebase• Crack is made by chemically altering cocaine powder to Crack is made by chemically altering cocaine powder to

form ‘rocks’form ‘rocks’• Latest figures state the street cocaine is only around 4% Latest figures state the street cocaine is only around 4%

pure. pure. • Cocaine is usually snorted whereas crack is smoked in a Cocaine is usually snorted whereas crack is smoked in a

pipepipe• Effects are more intense when smoked as crack as gets to Effects are more intense when smoked as crack as gets to

brain quicker – high lasts about 5 minutesbrain quicker – high lasts about 5 minutes• After the first pipe, the euphoric effects decrease and the After the first pipe, the euphoric effects decrease and the

withdrawal effects increase meaning people need to take withdrawal effects increase meaning people need to take more and moremore and more

• General effects are: alert, energetic, confident, mentally General effects are: alert, energetic, confident, mentally powerful, feel physically strong, increased heart rate, powerful, feel physically strong, increased heart rate, dilated pupils.dilated pupils.

• On intoxication, can lead to On intoxication, can lead to – agitation, suspiciousness, paranoia, impaired agitation, suspiciousness, paranoia, impaired

reality testing, impaired memoryreality testing, impaired memory• In withdrawalIn withdrawal

– depression, suspiciousness, paranoia, impaired depression, suspiciousness, paranoia, impaired reality testing, impaired memoryreality testing, impaired memory

• When cocaine is used with alcohol, the body When cocaine is used with alcohol, the body creates a substance called creates a substance called cocaethylenecocaethylene, which is , which is toxic to both heart and liver and which remains in toxic to both heart and liver and which remains in the body for up to four or five days.the body for up to four or five days.

• Use can lead to depression and suicidalityUse can lead to depression and suicidality• Formication – ‘cocaine bug’ – sensation of insects Formication – ‘cocaine bug’ – sensation of insects

crawling under your skincrawling under your skin

• May also be used to augment hypomania, temporarily May also be used to augment hypomania, temporarily relieve depression and counteract hyperactivity and relieve depression and counteract hyperactivity and ADHD.ADHD.

• Risk of violence and acquisitive offending either when Risk of violence and acquisitive offending either when high or when on withdrawal and cravings in order to high or when on withdrawal and cravings in order to purchase morepurchase more

• Crack and cocaine may be taken in order to give Crack and cocaine may be taken in order to give permission to offend, either by numbing affect/feelings of permission to offend, either by numbing affect/feelings of empathy, or through increasing confidence and feelings empathy, or through increasing confidence and feelings on invincibilityon invincibility

• Forensic patients frequently say they acted in ways Forensic patients frequently say they acted in ways when they were high on crack which they would not do if when they were high on crack which they would not do if they were straight.they were straight.

• Crack and cocaine use associated with unsafe sexual Crack and cocaine use associated with unsafe sexual behavioursbehaviours

• Addiction to crack can lead to sex working (in both males Addiction to crack can lead to sex working (in both males and females) and the associated risks of STD’s.and females) and the associated risks of STD’s.

HeroinHeroin

• opiate based pain-killer/sedativeopiate based pain-killer/sedative• Class AClass A• Known as smack, brown, scag, junk, H. Derived from the Known as smack, brown, scag, junk, H. Derived from the

opium poppy and medical name is Diamorphine.opium poppy and medical name is Diamorphine.• very addictive, both physically and psychologically very addictive, both physically and psychologically

especially when injected, can also be smoked.especially when injected, can also be smoked.• withdrawal symptoms physically very unpleasantwithdrawal symptoms physically very unpleasant

• Withdrawal symptoms (onset within 6 hours, and peak at 36-48 hours, lasts up to 7 days) include:Intense craving, restlessness, insomnia, pain in muscles and joints, running nose and eyes, sweating, abdominal cramps, vomiting, piloerection, dilated pupils, disturbance of temperature control

• But can lead to anxiety and depressionBut can lead to anxiety and depression• associated with personality disordersassociated with personality disorders• In London, heroin is approximately 40% pure In London, heroin is approximately 40% pure

on the street. The rest can be anything such on the street. The rest can be anything such as glucose, brick dust, lactose, baking as glucose, brick dust, lactose, baking powder, gravy browning and basically powder, gravy browning and basically anything that resembles heroin. anything that resembles heroin.

• Is a pain killer/emotional numbing – PTSD Is a pain killer/emotional numbing – PTSD and abuseand abuse

• May attenuate feelings of rage or violenceMay attenuate feelings of rage or violence• Can also however increase feelings of Can also however increase feelings of

confidence and invincibility.confidence and invincibility.

Ecstasy/MDMAEcstasy/MDMA• currently not clear about long term effects – currently not clear about long term effects –

depression? Cognitive function - research is depression? Cognitive function - research is still inconclusivestill inconclusive

• may cause low mood in days following use - may cause low mood in days following use - ‘suicide Tuesday’‘suicide Tuesday’

• is a hallucinogen so may be linked with is a hallucinogen so may be linked with increase in symptomsincrease in symptoms

• disrupted sleep associated with use, disrupted sleep associated with use, especially in clubbing cultureespecially in clubbing culture

• In media, reports that can help those to In media, reports that can help those to access memories of trauma and reduce access memories of trauma and reduce anxiety/distress levelsanxiety/distress levels

• So use could also be self-medicating for So use could also be self-medicating for PTSD symptomsPTSD symptoms

Crystal MethCrystal Meth

• Derivative of amphetamineDerivative of amphetamine• Commonly used in non-EU countries but recently use Commonly used in non-EU countries but recently use

has started to increase in the UKhas started to increase in the UK• Can be found in tablet, powder or crystal formCan be found in tablet, powder or crystal form• Crystal form, known as crystal meths or ‘ice’ can be Crystal form, known as crystal meths or ‘ice’ can be

smoked and is most potent and harmfulsmoked and is most potent and harmful• Rush of 5-30 minutes depending on administration and Rush of 5-30 minutes depending on administration and

high last for 8-24 hourshigh last for 8-24 hours• Causes increased arousal and motor activity, Causes increased arousal and motor activity,

disinhibition, diminished fatigue, sleep and appetite.disinhibition, diminished fatigue, sleep and appetite.

• Can lead to MA induced psychosis even after brief Can lead to MA induced psychosis even after brief period of useperiod of use

• Long term use can also lead to brain damageLong term use can also lead to brain damage

• Premorbid schizoid/schizotypal PD may predispose Premorbid schizoid/schizotypal PD may predispose MA users to psychosis and the greater the MA users to psychosis and the greater the vulnerability, the longer the psychosis will persistvulnerability, the longer the psychosis will persist

• Use seems to be particularly linked to unsafe sexual Use seems to be particularly linked to unsafe sexual behaviour and transmission of STDsbehaviour and transmission of STDs

• Paranoia and agitation especially linked to violence, Paranoia and agitation especially linked to violence, both from use and withdrawalboth from use and withdrawal

Other common drugsOther common drugs• Speed/amphetamines (stimulant) - disordered thinking, paranoia,

restlessness, poor sleep, hallucinations - use can trigger psychosis in vulnerable

individuals and create psychotic like symptoms when taken in large amounts

- exacerbates positive symptoms

• LSD/Acid – can trigger psychosis in vulnerable individuals

• Miaow miaow• Khat

Principles of Integrated TreatmentPrinciples of Integrated Treatment

Harm reduction• Treat/investigate medical problems e.g. BBV, access to

food/vitamins, stable housing/finance, moderation goal, substitution therapy.

• Time unlimited services

- to allow long-term change• Motivation-based treatment – motivational interviewing• Multiple psychotherapeutic modalities

- CBT based groups, 12 step programme, individual therapy, faith based rehabilitation.

The Wheel of Change

Permanent exit Maintenance Relapse

Action

Preparation

Pre-contemplation

Contemplation

BEGINS WITH

Ward based Stage 1 Groups

Stage 2 Groups and individual therapy

NA

Drug free support group

Lapse Interview