Week 4: Comorbidity and Behavioral Addictions
Week 4.1: Comorbidity
Psychosocial Treatments for People with Co-
Occurring Severe Mental Illnesses and SUDs
– Dual Diagnosis
Introduction
In the DSM – four categories of people are likely to require a combination of mental health
and substance abuse services:
(1) Those who are severely disabled by comorbid mental health and SUDs
- Who will need a coordinated and integrated approach by both mental health and
drug and alcohol services
(2) Those who are severely disabled by mental health disorders – and adversely affected
by problematic SUDs
- Who will be treated primarily by mental health services
(3) Those who are disabled by SUDs – and adversely affected by mental health problems
- Who will primarily be treated by drug and alcohol services
(4) Those who are mildly disable by dual diagnoses
- Who will be treated primarily by a general practitioner – but may also require
access to either mental health or substance use services at various times
The Epidemiologic Catchment Area (ECA) Study
The ECA study – revealed that 37% of those with alcohol disorders – and 53% with other
drug disorders
- Have comorbid psychiatric conditions
People with a diagnosis of SZ – were 3x more likely to be alcohol abusers
- And 6x more likely to abuse other substances
Correlates and Consequences of Living with Dual Diagnosis
,In general – people with psychosis and SUDs – are more likely to:
(1) Be male, (2) have family history of substance abuse, and (3) be younger than their
non-substance abusing counterparts
Negative consequences of dual diagnosis – include increased rates of:
(1) Treatment noncompliance, (2) relapse, (3) distorted perception and cognition, (4)
suicidal ideation, (5) social exclusion, (6) homelessness, (7) aggression, (8) injury,
etc.
Common Factors – Avoidance of Treatment
A common factor – contributing to the refusal or avoidance of treatment by dual-diagnosis
clients – is their low motivation to reduce substance use
(1) As a result – their mental health is especially vulnerable
- Their SUD may destabilize their illness, undermine treatment adherence, and
contribute to psychosocial instability
The mixture of psychosis, strong emotions, and the continuing resort to substances
- Will exacerbate social alienation – and increase the potential for violent outbursts
Friends and family – who live with, care for, or remain in contact with people having dual
diagnosis
(1) Will experience distress, tension, and conflict within these relationships
- Interpersonal conflicts – are often associated with dual diagnoses – and friends
and family may be frustrated with ongoing substance misuse – users themselves
may see as unproblematic
Reasons for Substance Use Among People with a Psychosis
Four General Hypotheses
There are four general explanations – for the high rates of substance use among people with
SZ – the hypotheses include:
(1) Substance abuse causes SZ
(2) Substance use is an attempt – by self-medication – to ameliorate experiences intrinsic
to SZ
, (3) SZ and substance abuse – have common etiological factors
(4) SZ and substance abuse maintain each other
Substance Use Causes SZ – Cannabis
Cannabis is the only substance – to have shown a strong association between substance abuse
– and the development of SZ
- Although most people who smoke cannabis – do not develop a psychotic illness
Substance Use as Self-Medication
In regards to the second hypothesis – summarized 11 research projects
- That explored reasons people with psychotic diagnoses use substances
Eight of the 11 studies – included patients with conditions that frequently include mood
alterations
Depression and Socializing
Depression relief – a commonly proposed reason for substance use
- These mood alterations may confound any apparent cause-and-effect relationships
More than 80% of participants – declared their reasons for using alcohol and cannabis
- Were to relieve (1) depression, (2) anxiety, or (3) boredom – or to relax
The next most common reason – related to socializing
Depression and socializing – are NOT deemed to be criteria for diagnosis of SZ
- Research refutes the self-medication hypothesis
Psychosis
People with psychosis – may have poorly developed problem-solving skills – and limited
resources to gain an improved sense of well-being
- Resulting in them resorting to using readily available, cheap, and not unduly
stigmatizing substances
Common Etiological Factors – SZ and Substance Abuse
There is no evidence that substance abuse and psychoses have a common genetic basis
, (1) However – the emotional, social, and biological sequelae of early childhood trauma
- May constitute an increased vulnerability to both conditions
Early Childhood Trauma
People who undergo physical or sexual abuse in childhood – are more prone to subsequent
substance abuse
- As many as 80% of women seeking assistance for SUDs – report sexual and
physical assaults
For some – childhood abuse increases their risk of developing a psychosis later
- And women with dual diagnoses – often have a trauma history as both children
and adults
Often there are emotional and social consequences – of experiencing assault, of emotional
neglect during childhood, or of witnessing violence against a parent
- Which increase one’s vulnerability to both psychoses and substance abuse
SZ and Substance Abuse Maintain Each Other
Is it highly likely – that there is a synergism b/n cannabis use and a predisposition to
psychosis
- And the vulnerability may be especially great during puberty
Mental illness and substance abuse – may interact in ways that maintain and exacerbate
each other
People who live with a psychosis – may have unrealistic, strongly held beliefs – about the
usefulness of drugs such as alcohol and cannabis
(1) People with SZ – commonly have low self-esteem – along with poorly developed
coping skills
- Under these circumstances – emotional, social, or symptom-related cues – can
provoke recourse to available substances
Treatment Issues Regarding People with Dual Diagnoses
Foundational Factors – Treatment Considerations
Week 4.1: Comorbidity
Psychosocial Treatments for People with Co-
Occurring Severe Mental Illnesses and SUDs
– Dual Diagnosis
Introduction
In the DSM – four categories of people are likely to require a combination of mental health
and substance abuse services:
(1) Those who are severely disabled by comorbid mental health and SUDs
- Who will need a coordinated and integrated approach by both mental health and
drug and alcohol services
(2) Those who are severely disabled by mental health disorders – and adversely affected
by problematic SUDs
- Who will be treated primarily by mental health services
(3) Those who are disabled by SUDs – and adversely affected by mental health problems
- Who will primarily be treated by drug and alcohol services
(4) Those who are mildly disable by dual diagnoses
- Who will be treated primarily by a general practitioner – but may also require
access to either mental health or substance use services at various times
The Epidemiologic Catchment Area (ECA) Study
The ECA study – revealed that 37% of those with alcohol disorders – and 53% with other
drug disorders
- Have comorbid psychiatric conditions
People with a diagnosis of SZ – were 3x more likely to be alcohol abusers
- And 6x more likely to abuse other substances
Correlates and Consequences of Living with Dual Diagnosis
,In general – people with psychosis and SUDs – are more likely to:
(1) Be male, (2) have family history of substance abuse, and (3) be younger than their
non-substance abusing counterparts
Negative consequences of dual diagnosis – include increased rates of:
(1) Treatment noncompliance, (2) relapse, (3) distorted perception and cognition, (4)
suicidal ideation, (5) social exclusion, (6) homelessness, (7) aggression, (8) injury,
etc.
Common Factors – Avoidance of Treatment
A common factor – contributing to the refusal or avoidance of treatment by dual-diagnosis
clients – is their low motivation to reduce substance use
(1) As a result – their mental health is especially vulnerable
- Their SUD may destabilize their illness, undermine treatment adherence, and
contribute to psychosocial instability
The mixture of psychosis, strong emotions, and the continuing resort to substances
- Will exacerbate social alienation – and increase the potential for violent outbursts
Friends and family – who live with, care for, or remain in contact with people having dual
diagnosis
(1) Will experience distress, tension, and conflict within these relationships
- Interpersonal conflicts – are often associated with dual diagnoses – and friends
and family may be frustrated with ongoing substance misuse – users themselves
may see as unproblematic
Reasons for Substance Use Among People with a Psychosis
Four General Hypotheses
There are four general explanations – for the high rates of substance use among people with
SZ – the hypotheses include:
(1) Substance abuse causes SZ
(2) Substance use is an attempt – by self-medication – to ameliorate experiences intrinsic
to SZ
, (3) SZ and substance abuse – have common etiological factors
(4) SZ and substance abuse maintain each other
Substance Use Causes SZ – Cannabis
Cannabis is the only substance – to have shown a strong association between substance abuse
– and the development of SZ
- Although most people who smoke cannabis – do not develop a psychotic illness
Substance Use as Self-Medication
In regards to the second hypothesis – summarized 11 research projects
- That explored reasons people with psychotic diagnoses use substances
Eight of the 11 studies – included patients with conditions that frequently include mood
alterations
Depression and Socializing
Depression relief – a commonly proposed reason for substance use
- These mood alterations may confound any apparent cause-and-effect relationships
More than 80% of participants – declared their reasons for using alcohol and cannabis
- Were to relieve (1) depression, (2) anxiety, or (3) boredom – or to relax
The next most common reason – related to socializing
Depression and socializing – are NOT deemed to be criteria for diagnosis of SZ
- Research refutes the self-medication hypothesis
Psychosis
People with psychosis – may have poorly developed problem-solving skills – and limited
resources to gain an improved sense of well-being
- Resulting in them resorting to using readily available, cheap, and not unduly
stigmatizing substances
Common Etiological Factors – SZ and Substance Abuse
There is no evidence that substance abuse and psychoses have a common genetic basis
, (1) However – the emotional, social, and biological sequelae of early childhood trauma
- May constitute an increased vulnerability to both conditions
Early Childhood Trauma
People who undergo physical or sexual abuse in childhood – are more prone to subsequent
substance abuse
- As many as 80% of women seeking assistance for SUDs – report sexual and
physical assaults
For some – childhood abuse increases their risk of developing a psychosis later
- And women with dual diagnoses – often have a trauma history as both children
and adults
Often there are emotional and social consequences – of experiencing assault, of emotional
neglect during childhood, or of witnessing violence against a parent
- Which increase one’s vulnerability to both psychoses and substance abuse
SZ and Substance Abuse Maintain Each Other
Is it highly likely – that there is a synergism b/n cannabis use and a predisposition to
psychosis
- And the vulnerability may be especially great during puberty
Mental illness and substance abuse – may interact in ways that maintain and exacerbate
each other
People who live with a psychosis – may have unrealistic, strongly held beliefs – about the
usefulness of drugs such as alcohol and cannabis
(1) People with SZ – commonly have low self-esteem – along with poorly developed
coping skills
- Under these circumstances – emotional, social, or symptom-related cues – can
provoke recourse to available substances
Treatment Issues Regarding People with Dual Diagnoses
Foundational Factors – Treatment Considerations
