Considerations in Assessing Co-Occurring Disorders Part 2

Continued from “Considerations in Assessing Co-Occurring Disorders Part 1”

While it is important to learn as much as possible about a client’s history this is not always possible. If they present much later in life without collateral information and require intensive inpatient treatment sometimes you need to start with where they are and treat the symptoms as they have completed the detox and some of the PAW’S period (post-acute withdrawal) then treat the “Clusters” of disorders represented as they emerge. There have been times that clients have not really come out of the condition that they came in for and some have developed critical medical sequalae and unfortunately passed away. For example, GHB dependency in a relatively young patient that suffered a heart attack while detoxing; a patient with methamphetamine induced mania with psychotic features that did not resolve over a year even given appropriate medications. The patient was later admitted to a “nursing home” with continued visual hallucinations and changes in mental status that continued.  I believe that a trial of cholinesterase Inhibitors was the next thing to be tried.  We know that in scenarios such as these there are many potential causal acute physiological mechanisms such as hypoxia, organ failure, and more gradual processes such as genetic alterations (epigenetics) so causal etiology is complex.  But just as there have been some very tragic outcomes in long term substance abuse there have also been some triumphant, almost miraculous ones.  With much determination and dedication to life change clients have turned their lives around and some in amazing ways:  at least two came off the liver transplant lists and one of those was able to do something he always dreamed of:  walk out of the house he had been “stuck” in for years and ride a bike he had never ridden in the last 25 years.

As in the case of genetic variability with the breakdown of alcoholic beverages that has been observed across some ethnic groups, there are people that have genetic vulnerabilities to have “severe reactions” to some substances for example like LSD. I have seen some one-time users of LSD have Hallucinogen Persisting Perception Disorders severe enough so that college students had to take significant time off school.  Also, some patients have had bad reactions to ketamine trials, so it is important to fully investigate a potential patient’s previous history and go over all potential outcomes.   This is not to take away from the positive effects of ketamine and other alternative agents that are being used for resistant depression, just a note of caution using them.

We know that environment, genetics, and brain structure (neural reserve) all can contribute to the potential to develop substance use disorders. Also, untreated Anxiety, Depression, Bipolar, untreated ADD can also raise the risk… as well as some other psychiatric disorders.   In fact, we know by what percentage for each disorder… Given these if a provider went back and took a good family and client history we could likely see what came first and whether there was adequate treatment of psychiatric issues early on, also whether there was trauma, whether there was family loading genetically for substances issues specifically genetic loading vs. environmental modeling and we could see likely what had happened in the past. Still a client’s history can change over time, and we would still look for “red flags” to clarify the psychiatric diagnosis all along as it may take time to show itself… Much like in eating disorders which often start off with anxiety/OCD also traits of perfectionism and move forward to control issues and later these “morph” into full blown eating disorders. Then the rituals become a way to manage anxiety and exert control.   In any “vulnerable combination” of these traits   in a human that is uncomfortable, they may seek a way to find some relief even if it leads to more distress down the line. And so it goes with self-medicating, anxiety, depression with other alcohol or drugs. But eventually with substances like sedatives, alcohol, opiates, and stimulants,” these agents stop working” due to tolerance issues and even with the increase for potential harm, and lack of efficacy due to complex cue reinforcement issues use of substances often persists. It is also important to emphasize that active and persistent substance use can “undue” the positive effects of medications.    A good example is lithium medication in a client that is drinking heavily. In some psychiatric disorders such as schizophrenia, becoming more resistant to treatment can go up as time goes by. And this costs the individual immensely, in terms of lost time: financially, socially, cognitively and medically.

So, in summary treating Co-occurring Disorders requires giving attention to all the Disorders simultaneously and attempting to keep them in remission. It requires psychoeducation and helping clients understand that it really is about all their “inclinations” or “disorders “and not one or the other and that developing a behavioral, cognitive approach (CBT) or some ongoing therapeutic support as well as psychopharmacology as needed and social support network.  Without “internalized “change, behavior and developmental level would be more chaotic and externally focused as well as intent   toward avoiding consequences with a continuance of exacerbations and treatments where the “dragon is chasing its tail” … and this could be become an isolative, progressively destructive course.  Or it could become the decision that this battle is more easily won in the beginning…in a supportive nonjudgemental yet targeted integrative treatment plan that focusses on promoting client self-autonomy. This has in my experience been based on forming a respectful alliance that includes harm reduction in treatment style but “plants the seeds” of progressive growth”.  It is respectful and nondogmatic and revolves around personality style and strengths and pulls together a treatment strategy much like a conductor of an orchestra interweaves the harmonious work of a great composer.