Dual Diagnosis Case Studies

Mark Holland PhDConsultant Nurse

Manchester Mental Health & Social Care Trust14.3.12

Leeds Dual Diagnosis Network

Introduction

• Background care cluster 16 (dual diagnosis of severe mental illness and substance misuse)

• Cluster 16 needs and treatment guide• Case studies• Dual diagnosis beyond psychotic cluster 16• Discussion and Conclusion

Cluster 16Cluster Description :

This group has enduring, moderate to severe psychotic or affective symptoms with unstable, chaotic lifestyles and coexisting substance misuse. They may present a risk to self and others and engage poorly with services. Role functioning is often globally impaired

Diagnoses:F20 -29 (Schizophrenia , schizotypal & delusional disorders)F30 – 31 (Bi-Polar Disorder)F32.3 (Severe depressive episode with psychotic symptoms)

Plus/withF10 – 19 (Mental & behavioural disorders due topsychoactive substance use)

Risk :Overdose (intentional/accidental)Entry into CJSHarm to selfHarm to others/From others

Course:Long term – 3 yrs +

C 16 Expected Needs

• Medication management/pharmacology• Health education/harm minimization• Engagement• Motivational interviewing• Social inclusion

C 16 Partnership working

• Substance misuse services (all sectors)• CJS (probation/prisons/police)• Housing • Employment

Core Elements of Care

Direct• Engagement, Motivational interviewing techniques,

CBT techniques, Harm minimisation/health promotion, Assertive Outreach Approach, Medication management, Assistance to increase social functioning, Relapse prevention strategies,

• As appropriate, advise/signpost/access self-help (e.g. groups), self-monitoring (e.g. triggers, early warning signs),Indirect

• Supportive & empathic relationships, provide hope

C16 Pathway NeedsCRISIS MANAGEMENTManagement of intoxicationMental health relapseCARE COORDINATION Should be under mental health service CPACare coordination by someone experienced (level 3 capability framework)Drug/alcohol relapseMONITORING OF PHYSICAL AND MENTAL HEALTH This should be the same as the other psychotic clusters with minimum of neuroleptic therapy NICE guide and attendance to BBV treatments and adviceDETOX & REHABAccess to detox (complex cases capability)Admission to appropriate complex needs rehabilitation

C16 QUALITY AND OUTCOMES GOALS

• Maximise quality of life and physical health• Maintain appropriate contact (SBNT)• Symptom management• Prevent general worsening of condition• Reduce risks (including Safeguarding)• Support recovery hopes (both domains)• Relapse prevention (both domains)• Preventing complications associated with illness and

medication as relevant (harm reduction and health promotion/ illness prevention)

Case Presentation 1: Christian

General implications and exercise / discussion

Demographic

• 24 year old male Caucasian • Lives between parents and girlfriends• Has a 2 year old child • Has a 14 year old brother• Unemployed for 18 months, prior to onset of

psychosis held various ‘blue collar’ jobs• Prison age 20 (violent offence in organised

crime, served 3 years)

Past History 15-23• Moderate alcohol• Cannabis age 15 to present

– Initially symptom free• Cocaine age 17 intermittent, no use for past 6 months

– Noted by family to be intense in manner and hold emphatic beliefs about Free Masons and Illuminati

• Heavier cocaine use late teens– Became involved in crime

• No IV use, no BBV’s despite long term shared insufflation • Abstained whilst in prison

– No treatment in prison, no reported symptomatology• On release drinking increased

– Family raised concerns with GP about growing preoccupation with Illuminati and expression of related paranoid ideas, grandiose flavour

Past History 22/23

• Concerns • Putting out cigarettes on forearms• Isolating himself• Striking his girlfriend• Shouting at family (HEE reaction / household)• Increased alcohol use• Little cocaine or cannabis use• Referred to CRHT, poor engagement both parties but

‘calmer’• Referred to dual diagnosis service (DDS)

DDS Presentation• Type I Diabetes• No residual self harm damage or acts• FTD, True auditory hallucinations, paranoid delusions with grandiose overtones,

derealisation, depersonalisation, with ?Capgras syndrome• Generalised anxiety both motor and autonomic• Variable mood (prominent paranoia = low mood versus prominent grandiosity –

high mood) • Verbal expressions of anger towards family and girlfriend (HEE environment)• Isolating himself• Alcohol used to avoid/reduce anger and alleviate anxiety• Anxiety correlates to delusional beliefs (even when grandiose)• Disturbed / reversed sleep pattern• Increasing alcohol misuse (relief drinking noted) and complications• Fluctuating rapport from guarded and suspicious to engaging (desperate for help)

Provisional Diagnosis and Management

• Paranoid Schizophrenia / alcohol induced psychotic disorder with hallucinations and delusions

• Alcohol harmful use / dependence syndrome

• Neuroleptic Therapy• Vitamin Therapy • Motivational Interviewing

– Alcohol education and information– Alcohol reduction / detox (community/ inpt)

• CMHT referral• Alcohol Service referral?

Exercise

• In groups or pairs please list the possible additional issues– E.g. Safeguarding, risk to staff, other services for

cannabis, cocaine and other drugs, engagement issues, individual / family CBT etc

• List issues that have emerged in your practice with similar patients

• List services you have referred to or know of that may help Christian

Case Presentation 2: Kelly

Motivational interviewing / Cognitive behavioural approach for

distress, symptoms, motivation and coping

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Overview• 29 year old woman • 2nd generation African Caribbean • Lives alone in well kept flat• 2 friends, one of whom visits 5 times a week• Pet cat• Limited contact with adoptive parents or siblings (all white British) for

past 6 or 7 years• Split from them was acrimonious (elements of illness associated)• Diagnosed paranoid schizophrenia 6 years ago• Previous schizotypal personality disorder diagnosed (PD label has

stuck)• Receives fortnightly risperidone consta 37.5mg• On 3rd antidepressant • Smokes skunkweed daily• Crack cocaine and heroin smoked as treat fortnightly • Hep C (prior IV use)

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Mental health distress

• Paranoid feelings – constant and pre curser to…• …Paranoid ideation – conviction level increases

rapidly when outside among strangers and friends alike

• General anxiety – psychomotor and autonomic• Social anxiety / phobia• Marked depression• Anger – specific to adoptive parents or at times

of paranoid ideas of reference• Feelings of rage – free floating (and sometimes

attached to adoptive family)

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Paranoid ideation

• No consistent delusional belief elicited• Feels under constant surveillance but guarded when

describing / cannot elaborate (most days, throughout the day)

• Manageable when smoking cannabis and in her flat• Ideas of reference from variety of sources when out• Not specific to same individuals or groups• History of violent response (stabbed a male

stranger who voices said had raped her)• Accompanied by true auditory hallucinations• Paranoid ideation conviction rating 80-90%

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Hallucinations• Does not recognise voices• 2nd and 3rd person• Derogatory, volume and intrusiveness varies• Command

– in revengeful mode (rape victim)– Harm self

• Occur on majority of days• Coping

– Cannabis and isolation = can cope– Cannabis and going out = sometimes cope– No cannabis and out = cannot cope – Mood relieved by crack cocaine and heroin

• Voices conviction rating 90%

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Brief analysis of substance misuse

PROS• Feels chilled - relaxant

effect (short lived)• Boosts confidence• Reduces feelings of rage

and anger• Enhances music• Something to do• Relieves low mood

CONS• Costly >1 ounce cannabis a

week (£100+); much as can afford of crack and heroin

• Conflicts with personal image of self reliance and physical fitness (previously fitness instructor)

• Feels dependent on it• Artificially relieves anxieties• Artificially creates euphoria• Reduces sleep quality

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Focus on one ‘PRO’ - Chilled

• Voices less intrusive and voluble• Anxiety (autonomic) diminishes

– Headaches, physical tension remains quite marked• Paranoid ideation - unchanged in conviction &

frequency, less intrusive however• Feelings of rage and anger about family less

dominant • Objective – emphasise the self medication

aspect that then reappears in a ‘con’

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Focus on one ‘CON’ – artificially relieves anxiety and improves mood

• Demonstrates insight of this maladaptive coping strategy (i.e. Short lived)– “there must be a way I can cope, without drugs, like other

people do” led to “I used to manage OK”• Connects ‘artificial’ psychoactive effect to her

personal image belief of health and self reliance– “I feel less depressed when I’m stoned but it’s wrong to

rely on it….and that thought makes me feel low…especially when I’m no longer stoned”

• Both statements demonstrate motivation to change

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Motivation

• Necessary prior to cognitive behavioural work– Shared goals and agenda

• Building motivation through motivational interviewing – Strategies such as decisional balance matrix (pros & cons) – Principles of empathy, rolling with resistance, developing

discrepancies, supporting self-efficacy• Preparation for cognitive work can start at

Contemplative stage of motivation

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MI Preparation

contemplation

preparation

action

maintenance

relapse

pre-contemplation

established change

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Decisional Balance Sheet

Good things

Not so Good

Not Change Change

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Importance and confidence

Confidence

Importance Readiness to change

0

10

10

28

Preparation - Cognitive Model

View of past

View of immediate life situation

View of future

Self-view

Affect

Cognitions Behaviour

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Beliefs that predispose to change

• My current behaviour is ‘bad’ for me (importance)

• I would be better off if I changed (importance)• If I try to change I can be successful

(confidence)• This is a good time to do it (readiness)

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Trigger/High Risk Situation

(out, paranoid feelings anxiety low mood)

Beliefs(cannabis is good for me, need it to get going, relieve tension/ anger,

craving)

Auto Thoughts(What the hell!

My life has turned out bad)

Cravings / positive anticipation

(physical and psychological – anticipated positive effect)

Permissive thoughts

(I deserve not to suffer this tension,

it’s not my fault)

Urge / Focus on Action(Score, roll joint - relief

begins)

Use / lapse / relapse(relief

obtained)

Sequalae(dissonance- feel bad / weakened resolve; relief short-lived)

Susceptibility to Triggers

Coming up with a ‘Relapse Cycle’ or case formulation

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Beliefs about substances that contribute to cravings and urges

BELIEF PROCESS REPLACEMENT BELIEFS

MAINTAINING STRATEGIES

AFFIRMED REPLACEMENT BELIEFS

Anticipatory

Expectations(relief- orientated)

Permissive

Catastrophic

Assess, examine and test out belief

(Socratic questioning, guided discovery)

Not as good as expected

Temporary relief only

I used to do good satisfying things so I could do them again

It’s not my fault but I can do something else

It can improve, this is a lapse not a relapse

‘Cons’ flashcard

Success flashcard

Activity schedule

Supporters / sponsors

Imagery techniques

I can get relief elsewhere / other ways

I can do things OK

I don’t need it.

Document and reference (flash card, anchor memories)

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Trigger/High Risk Situation

(out, paranoid feelings anxiety low mood)

Beliefs(good/bad for me, need a joint to get

going, relieve tension/ anger,

craving)

Auto Thoughts(What the hell!

My life has turned out bad)

Cravings(physical and

psychological – anticipated positive effect)

Permissive thoughts

(I deserve not to suffer this tension,

it’s not my fault)

Urge / Focus on Action(Score, roll joint - relief

begins)

Use / lapse / relapse(relief

obtained)

Sequalae/ catastrophic

(dissonance- eel bad / weakened

resolve, it’s getting worse)

Susceptibility to Triggers Red – Cognitive

Green - behavioural

Relapse Cycle: Opportunities for Intervention

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Considering and selecting symptoms Mood Antidepressants, CBT, Counselling,

psychotherpayCognitive / thinking

Examine (and test) cognitive errors such as personalisation, over generalisation, dichotomous thinking, and harsh self-criticism.Examine, (test) and reframe core beliefs such as I’m helpless, nothing works for me, I’m alone, I’m stupid, life is empty, it’s good for me, I need it to get going.Introduce replacement beliefs such as relief is temporary, I used to manage OK without itReattribution of responsibility (extrinsic factors to internal factors – empowerment / self-efficacy)

Behavioural Activity schedule, relapse prevention suicide prevention, social skills- assertiveness, vocational, employment, ‘cons’/ success flash cards, PMR relaxation

Physiological Sleep hygiene, hypnotics, activities, anxiety management

Motivational Pros and cons of current use / behaviour (wishes to escape - suicide / drugs), importance & confidence

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Imagery techniques

• STOP (spoken volubly) and MIND’S EYE visual imagery of stop sign, police officer, relative, sponsor

• IMAGE REPLACEMENT by empty wallet, hangover, physical injury, poor health, victim

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Exercise (optional)

• Groups of 4-6 people• Identify an existing client

Or• Create your groups own client• Create a Relapse Cycle• Highlight potential intervention opportunities within

the relapse cycle Cognitive / behavioural / social / pharmacological

• Make a few notes for a brief feedback (if we’ve time!)

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A – FRAMES

• Assessment (thorough but not at expense of engagement)

• Feedback (accurate and specific to assessment)• Responsibility (clients but may need graduating)• Advice (accurate, evidenced & neutral)• Menu (of options)• Empathy (avoid confrontation and resistance)• Self – efficacy

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Conclusion

• Initial Focus on Engagement• Thorough Assessment

– Symptom selection– Intervention choice

• Motivational Interviewing – Preparation Cognitive-Behavioural Techniques - Action

• Timing, perseverance and optimism

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Did it work?

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There is an alternative!Russians thrash drug takers to stop addiction

“On the first day we beat them with belts until their buttocks turn blue.Every week we have to buy a new belt because they go too soft, but we have been impressed with the quality of Gucci belts.Drug addicts are animals who have lost all sense of values. This way, the next time they think about getting a fix they remember the pain of thethrashing rather than the rush of the drugs. It's very effective.

You cannot solve this with mild manners - you need tough measures”

City Without Drugs - Igor Varov Reported by Drugscope

Dual diagnosis beyond c 16

• HONOS substance misuse subscale rating is conventionally substance treatment orientated

• SMI & SM often need designating to 16 by care cluster rater

• No care cluster for non-psychotic DD (as yet)

Honos Substance Misuse Subscale

• Item Scoring:• 0= None: No problem of this kind during the period rated.• 1= Minor problem: Some over indulgence, but within social

norm.• 2= Mild problem; Loss of control of drinking or drug taking,

but not seriously addicted.• 3= Moderate problem: Marked cravings or dependence on

alcohol or drugs with frequent loss of control; risk taking under the influence.

• 4= Severe problems: Incapacitated by alcohol/drug problems.

End

• Any comments• Thank you• mark.holland@mhsc.nhs.uk