Welcome
Rogers treats children, adolescents
and adults with:
• OCD and anxiety disorders
• Depression and mood disorders
• Eating disorders
• Posttraumatic Stress Disorder
• Addiction
800-767-4411
rogersbh.org
Anxiety and Addiction
Michael M. Miller, MD, FASAM, FAPA
Lakeview Professional Lecture Series
Lakeview Health
Jacksonville, Florida
November 20, 2015
Michael M. Miller, MD, FASAM, FAPA
mmiller@rogershospital.org
Medical Director
Herrington Recovery Center
Rogers Memorial Hospital
Oconomowoc, Wisconsin
Clinical Adjunct
Professor
University of Wisconsin School of
Medicine and Public Health
Assistant Clinical Professor
Medical College of Wisconsin,
Department of Psychiatry and
Behavioral Health
Past President
American Society of Addiction Medicine
(ASAM)
Director
American Board of Addiction Medicine
(ABAM) and The ABAM Foundation
Fellow
ASAM and American Psychiatric Assoc.
Member
Council on Medical Quality and
Population Health,
Wisconsin Medical Society
Member
Council on Science and Public Health,
American Medical Association
Disclosures
Alkermes
a pharmaceutical firm
Honoraria: participation in training to be member
of speaker’s bureau, and for speaker’s bureau
presentations
Braeburn Pharmaceuticals
a pharmaceutical firm
Stipend: participation in physician advisory board
BioDelivery Sciences International (BDSI)
a pharmaceutical firm
Stipend: participation in physician advisory board
Honoraria: participation in training to be member
of speaker’s bureau, and for speaker’s bureau
presentations
Curry Rockefeller Group
a marketing consulting firm
Consulting: advising on content of patient
education materials for newly marketed
pharmaceutical; advising on content of postmarketing survey of patients receiving a
pharmaceutical; preparation of presentations for
national medical education conferences
American Academy of Addiction Psychiatry - 1987
• First ABPN CAQ Exam
• 1994
The Addiction Specialist Physician
• Addiction Medicine
– All specialties
– 2500 Diplomates
• Addiction Psychiatry
– Board certified general psychiatrists
– 1000 subspecialty Diplomates
www.theabpm.org
The newest multispecialty subspecialty
certification program in the
American Board of Medical Specialties
Anxiety and Addiction
Basic Premises
• Addiction is Common
• Anxiety is Common
• Many people with Anxiety use Substances
• Many people with Anxiety have Addiction
• Many people with Addiction have Anxiety
• Many people with Addiction have Anxiety Disorders,
Obsessive Compulsive and Related Disorders, and
Traumatic and Related Disorders
The Broader Context:
“Dual Diagnosis” -- Basic Premises
• Addiction is Common
• Mental Disorders are Common
• Many people with Mental Disorders have Addiction
• Many people with Mental Disorders have Unhealthy
Substance Use
• Many people with Addiction have
• Psychiatric Disorders
• Many people with Addiction have
• Psychiatric Symptoms
Dual Diagnosis
MI + CD
MI + unhealthy substance use
CD + psychiatric symptoms
Clinical Management is the Challenge
Dual Diagnosis
• This issue is one of science: what are the conditions
and how often do they co-occur?
• The issue is more one of clinical practice:
– How best do we meet the needs of patients?
• It’s also an issue of Health Care Financing and
Service Delivery:
– How do you design systems to meet clinical need, and
what are the funding streams and how do they impact what
is possible to do clinically?
The Clinical Challenge
• This patient has a problem that I don’t really know
how to address; what do I do?
– I am a chemical dependency counselor without psychiatric
training; something is amiss, I’m not sure what it is, and I
feel overwhelmed to respond
– I am a mental health clinician without addiction training; I
know this person is “using” but I’m not sure what and I’m
not sure what I can do for the patient if he/she is using; I
feel overwhelmed
The Clinical Challenge
• Even worse: I don’t see what I don’t know
• The patient has a co-occurring condition, and from
my perspective/experience/training, I don’t recognize
it and so I don’t address it, so it is missed, and clinical
outcomes suffer accordingly
• “System results” suffer, health care costs are greater
than necessary, relapse leads to re-admissions
(which in “old” systems of healthcare finance and
delivery, were “good” for providers!)
Dual Diagnosis:
Why is Clinical Management a Challenge?
The training of clinicians differs: MI + CD
The clinical orientation of clinicians differs.
Service Delivery Systems are separate.
Health Care Financing Systems are separate.
Dual Diagnosis
• In order to understand “dual” diagnosis, a clinician
should understand addiction AND mental disorders
(know “both parts”)
• In order to be able to effectively treat “dual diagnosis”
cases, a clinician should understand addiction
treatment approaches (psychosocial treatments and
pharmacotherapies) and psychiatric treatment
approaches (psychotherapies and medication
management)
Dual Diagnosis
Editorial comment (based on 3+ decades of experience):
• Among physicians, fewer psychiatrists understand addiction
or addiction treatment, compared to addiction medicine
physicians who understand psychiatric conditions and
treatments.
• Psychiatrists may have had little training in addiction or
exposure to recovery.
Dual Diagnosis
Editorial comment (based on 3+ decades of experience):
• Addiction medicine physicians have had some training in
medical school in psychiatry, and they see many cases of
psychiatric co-morbidity and acquire experience in the
management of common psychiatric disorders (not unlike
primary care physicians and emergency medicine
physicians, who “see” a lot of psychiatric presentations and
have some idea of how to at least prescribe medications for
straightforward presentations)
The Solution to the Clinical Challenges of
Dual Diagnosis
• Integrated Clinical Services
• Knowledgeable/Competent Staff:
• “Dually Licensed”
• Training
• Supervision
• Finances
Traditional Approaches
(= often ineffective)
• Non-existent
• Separate/Sequential
• Concurrent
Ideal: Integrated
Integrating Care for
Dual Diagnosis
Rogers Memorial Hospital
Rogers Behavioral Health System
Herrington Recovery Center
Michael M. Miller, MD, FASAM, FAPA
mmiller@rogershospital.org
800-767-4411
rogershospital.org
Anxiety and Addiction
• A lot of people with addiction are anxious
• A lot of people with addiction
• “self-medicate” their anxiety
• A lot of people with addiction have
• anxiety disorders, OCD, PTSD
• Is it true “dual diagnosis”?
• What are these conditions?
• How often to they occur?
Addiction
• DSM-IV and DSM-5 criteria
– Substance Dependence
– Substance Abuse
– Substance Use Disorders
– Substance Related Disorders
• Intoxication
• Withdrawal
• Substance Induced Disorders
• The ASAM Definition of Addiction
DSM-IV Criteria
“Substance Dependence”
1. Tolerance, as defined by either of the following:
a. a need for markedly increased amounts of the substance to
achieve intoxication or the desired effect, or
b. markedly diminished effect with continued use of the same amount
of the substance
2. Withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the substance, or
b. the same (or closely related) substance is taken to relieve or avoid
withdrawal symptoms
3. The substance is often taken in larger amounts or over a longer
period than was intended
4. There is a persistent desire or unsuccessful efforts to cut down
or control substance use
DSM-IV Criteria
“Substance Dependence”
5. A great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
6. Important social, occupational, or recreational activities are given up
or reduced because of substance use
7. The substance use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is
likely to have been caused or exacerbated by the substance
DSM-IV Criteria
“Substance Abuse”
1. A maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by one (or more) of the
following, occurring within a 12-month period:
a. recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home
b. recurrent substance use in situations in which it is physically hazardous
c. recurrent substance-related legal problems
d. continued substance use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the
substance
2. The symptoms have never met the criteria for Substance
Dependence for this class of substance. (major impact on
epidemiological research)
Substance Use Disorder Criteria: DSM-IV
Abuse
Dependence
Failure to fulfill obligations
X
--
Hazardous use
X
Substance-related legal problems
X
--
Social/interpersonal substance-related problems
X
--
Tolerance
--
X
Withdrawal
--
X
Persistent desire/unsuccessful efforts to cut down
--
X
Using more or over for longer than was intended
--
X
Neglect of important activities
--
X
Great deal of time spent in substance activities
--
X
Psychological/Physical use-related problems
--
X
1+ criteria
3+ criteria
Diagnostic Criteria
Diagnostic Threshold
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
Columbia University Deborah Hasin, Ph.D.
1+
--
3+
Substance Use Disorder Criteria:
DSM-IV and DSM-5
DSM-IV
DSM-V
Abuse
Dependence
Substance Use Disorder
Failure to fulfill obligations
X
--
X
Hazardous use
X
--
X
Substance-related legal problems
X
--
--
Social/interpersonal substance-related problems
X
--
X
Tolerance
--
X
X
Withdrawal
--
X
X
Persistent desire/unsuccessful efforts to cut down
--
X
X
Using more or over for longer than was intended
--
X
X
Neglect of important activities
--
X
X
Great deal of time spent in substance activities
--
X
X
Psychological/Physical use-related problems
--
X
X
Craving
--
--
X
1+ criteria
3+
Criteria
Moderate: 4-5 criteria
Severe: 6+ criteria
Diagnostic Criteria
Diagnostic Threshold
Columbia University Deborah Hasin, Ph.D.
11
criteria
DSM-5 Substance Use Disorder
Tolerance *
Withdrawal *
More use than intended
Craving for the substance
Unsuccessful efforts to cut down
Spends excessive time in
acquisition
• Activities given up because of
use
•
•
•
•
•
•
• not counted if prescribed
by a physician or other Rx-er
• Uses despite negative effects
• Failure to fulfill major role
obligations
• Recurrent use in hazardous
situations
• Continued use despite consistent
social or interpersonal problems
SUD MILD = 2 or more +
SUD MODERATE = 4 or more +
SUB SEVERE = 6 or more +
DSM-5: “Addiction and Related Disorders”
– Substance Use Disorders
– Substance Related Disorders
• Intoxication
• Withdrawal
• Substance Induced Disorders
– Other conditions
• Gambling Disorder
Addiction
American Society of Addiction Medicine • April 2011
Definition of Addiction:
“Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social
and spiritual manifestations. This is reflected in an individual
pathologically pursuing reward and/or relief by substance use
and other behaviors.”
Definition of Addiction
American Society of Addiction Medicine • April 2011
“Addiction is characterized by inability to consistently abstain,
impairment in behavioral control, craving, diminished recognition
of significant problems with one’s behaviors and interpersonal
relationships, and a dysfunctional emotional response. Like other
chronic diseases, addiction often involves cycles of relapse and
remission. Without treatment or engagement in recovery
activities, addiction is progressive and can result in disability or
premature death.”
Emotional changes in addiction
can include:
• Increased anxiety, dysphoria and emotional pain;
• Increased sensitivity to stressors associated with the
recruitment of brain stress systems, such that “things
seem more stressful” as a result; and
• Difficulty in identifying feelings, distinguishing
between feelings and the bodily sensations of
emotional arousal, and describing feelings to other
people (sometimes referred to as alexithymia).
The emotional aspects of addiction
are quite complex.
• Some persons use alcohol or other drugs or
pathologically pursue other rewards because they are
seeking “positive reinforcement” or the creation of a
positive emotional state (“euphoria”).
• Others pursue substance use or other rewards because
they have experienced relief from negative emotional
states (“dysphoria”), which constitutes “negative
reinforcement.“
• Beyond the initial experiences of reward and relief, there
is a dysfunctional emotional state present in most
cases of addiction that is associated with the persistence
of engagement with addictive behaviors.
The state of addiction is not the same as
the state of intoxication.
When anyone experiences mild intoxication through the use of
alcohol or other drugs, or when one engages non-pathologically
in potentially addictive behaviors such as gambling or eating, one
may experience a “high”, felt as a “positive” emotional state
associated with increased dopamine and opioid peptide activity in
reward circuits. After such an experience, there is a
neurochemical rebound, in which the reward function does not
simply revert to baseline, but often drops below the original
levels. This is usually not consciously perceptible by the
individual and is not necessarily associated with functional
impairments.
Over time, repeated experiences with substance use or
addictive behaviors are not associated with ever
increasing reward circuit activity and are not as
subjectively rewarding. Once a person experiences
withdrawal from drug use or comparable behaviors,
there is an anxious, agitated, dysphoric and labile
emotional experience, related to suboptimal reward and
the recruitment of brain and hormonal stress systems,
which is associated with withdrawal from virtually all
pharmacological classes of addictive drugs.
While tolerance develops to the “high,” tolerance does not
develop to the emotional “low” associated with the cycle of
intoxication and withdrawal. Thus, in addiction, persons
repeatedly attempt to create a “high”--but what they mostly
experience is a deeper and deeper “low.” While anyone may
“want” to get “high”, those with addiction feel a “need” to use
the addictive substance or engage in the addictive behavior in
order to try to resolve their dysphoric emotional state or their
physiological symptoms of withdrawal.
Persons with addiction compulsively use even though it may
not make them feel good, in some cases long after the pursuit
of “rewards” is not actually pleasurable.5 Although people from
any culture may choose to “get high” from one or another
activity, it is important to appreciate that addiction is not solely a
function of choice. Simply put, addiction is not a desired
condition.
The Absinthe Drinker, Edward Degas
Anxiety
• http://www.clevelandclinicmeded.com/medicalpubs/diseas
emanagement/psychiatry-psychology/anxiety-disorder/
• Anxiety is a natural response and a necessary
warning adaptation in humans. Anxiety can become a
pathologic disorder when it is excessive and
uncontrollable, requires no specific external stimulus,
and manifests with a wide range of physical and
affective symptoms as well as changes in behavior
and cognition.
Anxiety Disorders (DSM-IV)
• Disorders in this Category
Generalized Anxiety Disorder [GAD]
Panic Disorder (with or without Agoraphobia)
Agoraphobia (with or without a history of Panic Disorder)
Phobias (including Social Phobia)
Obsessive-Compulsive Disorder [OCD]
Posttraumatic Stress Disorder [PTSD]
Acute Stress Disorder
Substance-induced Anxiety Disorder
Anxiety secondary to a general medical condition
• Disorders outside of this Category
Trichotillomania
Anxiety Disorders
Obsessive-Compulsive and
Related Disorders
Based on a presentation originally given by Katharine A. Phillips, MD, as part of a
master course on the DSM-5 at the American Psychiatric Association 166th Annual
Meeting in San Francisco, California on May 18, 2013, and Rogers Memorial
Hospital presentations by Bradley C. Riemann, PhD.
DSM-5 Chapters
• Anxiety Disorders: generalized anxiety disorder; panic
disorder; agoraphobia; specific phobia; social anxiety
disorder (social phobia), separation anxiety disorder;
selective mutism
• Obsessive-Compulsive and Related Disorders:
obsessive compulsive disorder (OCD), body dysmorphic
disorder (BDD), hoarding disorder, trichotillomania (hairpulling disorder), excoriation (skin picking) disorder – NEW
CHAPTER
• Trauma- and Stressor-Related Disorders: PTSD; acute
stress disorder; adjustment disorders; reactive attachment
disorder; disinhibited social engagement disorder,– NEW
CHAPTER
Generalized Anxiety Disorder (GAD)
Generalized anxiety disorder is characterized by chronic feelings
of excessive worry and anxiety without a specific cause.
Individuals with generalized anxiety disorder often feel on edge,
tense, and jittery. Someone with generalized anxiety disorder
may worry about minor things, daily events, or the future. These
feelings are accompanied by physical complaints such as
elevated blood pressure, increased heart rate, muscle tension,
sweating, and shaking.
Generalized Anxiety Disorder (GAD)
According to the National Institute of Mental Health (NIMH), more
than 6.8 millions American adults suffer from generalized anxiety
disorder. More than twice as many women than men suffer from
the disorder. While the disorder can occur at any time throughout
the lifespan, it most often arises sometime between childhood
and middle age. GAD frequently occurs alongside another
problem including other anxiety disorders, substance abuse, or
depression.
Generalized Anxiety Disorder (GAD):
Symptoms
Excessive worry/no specific
source
Breathlessness
Exaggerated startle reflex
Nausea
Trembling
Inability to sleep due to worrying Excessive sweating
Stomach aches
Headaches
Fatigue
Muscle tension
Lightheadedness
From:
http://psychology.about.com/od/
psychiatricdisorders/
Social Anxiety Disorder
Social anxiety disorder, also called social phobia, is an anxiety
disorder in which a person has an excessive and unreasonable
fear of social situations.
Anxiety (intense nervousness) and self-consciousness arise from
a fear of being closely watched, judged, and criticized by others.
A person with social anxiety disorder is afraid that he or she will
make mistakes, look bad, and be embarrassed or humiliated in
front of others. The fear may be made worse by a lack of social
skills or experience in social situations. The anxiety can build into
a panic attack.
Social Anxiety Disorder
In addition, people with social anxiety disorder often suffer
"anticipatory" anxiety -- the fear of a situation before it even
happens -- for days or weeks before the event. In many cases,
the person is aware that the fear is unreasonable, yet is unable to
overcome it.
People with social anxiety disorder suffer from distorted thinking,
including false beliefs about social situations and the negative
opinions of others. Without treatment, social anxiety disorder can
negatively interfere with the person's normal daily routine,
including school, work, social activities, relationships.
Social Anxiety Disorder
People with social anxiety disorder may be afraid of a specific
situation, such as speaking in public. However, most people with
social anxiety disorder fear more than one social situation. Other
situations that commonly provoke anxiety include:
• Eating or drinking in front of others.
• Writing or working in front of others.
• Being the center of attention.
• Interacting with people, including dating or going to parties.
• Asking questions or giving reports in groups.
• Using public toilets.
• Talking on the telephone.
Social Anxiety Disorder
Social anxiety disorder may be linked to other mental illnesses, such as
panic disorder, obsessive compulsive disorder, and depression. In fact,
many people with social anxiety disorder initially see the doctor with
complaints related to these disorders, not because of social anxiety.
What Are the Symptoms of Social Anxiety Disorder?
Many people with social anxiety disorder feel that there is "something
wrong," but don't recognize their feeling as a sign of illness. Symptoms of
social anxiety disorder can include:
• Intense anxiety in, or avoidance of, social situations.
• Physical symptoms of anxiety, including confusion, pounding heart,
sweating, shaking, blushing, muscle tension, upset stomach, and
diarrhea.
Panic Disorder
• Panic disorder is different from the normal fear and anxiety reactions to
stressful events.
• It strikes without reason or warning.
• Symptoms of panic disorder include sudden attacks of fear and
nervousness, as well as physical symptoms such as sweating and a racing
heart. During a panic attack, the fear response is out of proportion for the
situation, which often is not threatening. Over time, a person with panic
disorder develops a constant fear of having another panic attack, which
can affect daily functioning and general quality of life.
• Panic disorder often occurs along with other serious conditions, such as
depression, alcoholism, or drug abuse.
http://www.webmd.com/anxiety-panic/guide/mental-health-panic-disorder
Panic Disorder
Symptoms of a panic attack, which often last about 10 minutes, include:
•
•
•
•
•
•
•
•
•
•
•
Difficulty breathing
Beyond the panic attacks
Pounding heart or chest pain
themselves, a key symptom of
Intense feeling of dread
panic disorder is the persistent
fear of having future panic
Sensation of choking or smothering
attacks. The fear of these
Dizziness or feeling faint
attacks can cause the person
Trembling or shaking
to avoid places and situations
Sweating
where an attack has occurred
or where they believe an attack
Nausea or stomachache
may occur.
Tingling or numbness in the fingers and toes
Chills or hot flashes
A fear that you are losing control or are about to die
DSM-5 Changes for Anxiety Disorders
• Panic Disorder:
– “Panic disorder with agoraphobia” and “Panic disorder
without agoraphobia” are combined into one disorder
named “Panic disorder”
– Clarifies that panic attacks can arise from a calm or
anxious state
• Separation Anxiety Disorder: Criteria slightly
modified to make them more applicable to adults, and
moved to Anxiety Disorders section
Craske et al, 2010, Bogels et al, in press
DSM-5 Changes for Agoraphobia,
Social Phobia, and Specific Phobia
• More consistency across the phobias – e.g., all
emphasize fear, anxiety, avoidance
• 6-month duration added to ensure not a transient, normal
experience
• Name change: social anxiety disorder (social phobia)
• Insight:
– Social anxiety disorder and specific phobia no longer
require that the patient recognizes that the fear is
excessive or unreasonable → replaced with phrasing that
makes this the clinician’s judgment
– But insufficient research to add an insight specifier
Craske et al, 2010
Some Changes for Anxiety Disorders
• Selective Mutism:
– Moved to Anxiety Disorders section
– Criteria unchanged from DSM-IV
• OCD and PTSD
– Moved to their own separate chapters
– Some other conditions brought into those groupings
New Disorders in Obsessive-Compulsive
and Related Disorders
Hoarding disorder
Excoriation (skin picking)
disorder
Why Add Hoarding Disorder to DSM-5?
• Substantial scientific literature on this disorder
• Fear they’ll discard something they’ll need at a later date, and don’t
trust their decision-making regarding sorting items into ‘save’ vs. ‘toss’
• Clinically significant hoarding is prevalent (2-5% of the population)
and can be severe, with resulting legal problems
• Most hoarders (up to 80%) do not meet diagnostic criteria for OCD
and do not endorse other clinically significant OCD symptoms
• There are important differences between hoarding and OCD across a
number of validators, including poorer response to SRIs and ERP
Mataix-Cols, Frost, Pertusa, et al: Depress Anxiety, 2010
Specifiers for Hoarding Disorder
• With Excessive Acquisition: Excessive acquisition
of items that are not needed or for which there is no
available space
• Insight:
– Good or fair insight
– Poor insight
– Absent insight/delusional beliefs
Trichotillomania (Hair-Pulling Disorder)
Core feature: Recurrent pulling out of one’s hair, resulting
in hair loss
Changes:
• Hair loss does not have to be noticeable
• Criteria B and C deleted (tension/gratification)
• Replaced with “repeated attempts to decrease or stop”
hair pulling
• Hair Pulling Disorder (in parentheses) added to the name
Stein et al, 2010
Why Add Excoriation (Skin Picking)
Disorder to DSM-5?
• Substantial scientific literature on this disorder
• Clinically significant skin picking affects 1-2% of the
population
• This problem can be severe, with resulting medical
sequelae such as infections, lesions, scarring, and
physical disfigurement
• This condition is not covered by any other disorders
in DSM
Stein, et al: Depress Anxiety, 2010
Excoriation (Skin Picking) Disorder
Features:
• Recurrent skin picking resulting in skin lesions (which
can be concealed)
• Repeated attempts to decrease or stop skin picking
• Causes clinically significant distress or impairment in
functioning
Excoriation (Skin Picking) Disorder, continued
• Skin picking is not attributable to physiologic effects of a
substance (e.g., cocaine, methamphetamine) or another
medical condition (e.g., scabies)
• Not better explained by symptoms of another mental
disorder, such as:
– Psychotic disorder (e.g., parasitosis)
– Body dysmorphic disorder (BDD): picking to improve perceived skin
defects or flaws
– Stereotypic movement disorder
– Non-suicidal self-injury: intent to harm oneself
Obsessive-Compulsive Disorder
(OCD; 300.3)
• DSM-V has created a new “Chapter” entitled Obsessive
Compulsive and Related Disorders. No longer placed in
Anxiety Disorders Chapter.
– OCD.
– Body Dysmorphic Disorder.
– Hoarding Disorder.
– Trichotillomania (Hair-pulling Disorder).
– Excoriation Disorder (skin picking).
Obsessive-Compulsive Disorder (OCD)
• OCD characterized by either obsessions or
compulsions (or both).
Obsessions
• Recurrent, and persistent thoughts, urges, or images
that are experienced as intrusive and unwanted and
cause marked anxiety or distress.
• Person attempts to ignore or suppress obsessions or
to neutralize them with some other thought or action
(i.e., compulsion).
Examples of Obsessions
• Contamination (1).
• Repeated doubt (2).
• Need for exactness or symmetry.
• Need to tell, ask, or confess.
• Harming.
• Sexual imagery.
• Religious.
Compulsions
• Repetitive behaviors or mental acts that the person feels
driven to perform in response to an obsession, or according to
rules that must be applied rigidly (i.e., ritual).
• Aimed at preventing or reducing distress or preventing some
dreaded event or situation; however, these compulsions either
are not connected in a realistic way or are clearly excessive.
Examples of Compulsions
• Checking (1).
• Washing or cleaning (2).
• Counting.
• Ordering.
• Repeating.
• Praying.
• Requesting assurance.
“Either” / “And” Questions
• DSM Criteria states that to have OCD, you need either
obsessions or compulsions.
• Symptom presentation (historical).
– Mixed
– “Pure” obsessional
– “Pure” compulsive
= 98%
= < 2%
= < 0.5%
• Doesn’t seem to match clinical experience at Rogers.
• Leonard & Riemann, 2012.
– Found that all 1,086 individuals in sample with OCD reported
having both (746 adults, 340 children).
• Suggest changing to “and”.
Some Changes for OCD
• Definition of obsession: “urge” replaces “impulse”
• “Unwanted” replaces “inappropriate” (different
cultures have different definitions of inappropriate)
• Changed to “in most individuals, causes marked
anxiety or distress”
• New tic-related specifier: Current or past history of a
tic disorder
Leckman, Denys, Simpson, et al, 2010
Diagnosis in OCD
• Specify if:
– With good or fair insight.
• Recognizes that OCD related beliefs are definitely or probably not
true (good) or that they may or may not be true (fair).
– With poor insight.
• Thinks OCD related beliefs are probably true.
– With absent insight/ delusional beliefs.
• Completely convinced OCD related beliefs are true.
Insight in OCD per DSM-5
1. Patients no longer must recognize that their OCD obsessions or
compulsions are excessive or unreasonable
• Neither “excessive” nor “unreasonable” were defined or
operationalized in DSM-IV, and they can have different meanings
• Some patients lack insight (indeed, DSM-IV has a “poor insight”
specifier)
2. Delusional variants of OCD (and BDD) are no longer in the
psychosis section; they are only with OCD (and BDD)
3. OCD’s poor insight specifier has been expanded to include a
broader range of insight options, including delusional OCD beliefs
Leckman, Denys, Simpson, et al, 2010; Phillips et al, 2010
Body Dysmorphic Disorder
Core feature: Distressing or impairing preoccupation with
perceived appearance defects or flaws that are not
observable or appear slight to others
Changes:
• New Criterion B: Requires repetitive BDD behaviors
• Insight specifier: Good/fair, poor, absent insight/delusional
beliefs
• Muscle dysmorphia specifier: Small or insufficiently
muscular body build
Phillips et al, 2010
OCD (continued)
• Specifier if:
– Tic-related.
• Individual has current or past history of a tic disorder.
• There is an INSIGHT specifier.
Commonly Asked Questions
• How common is it?
2.5%
• Any sex differences?
No
• Age of onset?
20.2 yrs. (males)
1-14 years
22%
– 15-24 years
42%
– 25-34 years
21%
– over 35 years
15%
– over 50 years
Rare
–
Commonly Asked Questions (continued)
• Course of OCD?
– 85% continuous course with minor fluctuations.
– 15% deteriorating course.
• Stress play a role?
– 50-60% report stressful trigger around onset.
– Almost all report increase in symptoms during stress.
Associated Features
• Secondary depressed mood (85%).
• Academic and occupational impairment.
• Low self-esteem.
• Social withdrawal.
• Family discord.
• Fear of embarrassment (hide symptoms).
• Avoidance.
Leading Causes of Disability (WHO)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Major Depression.
Iron-deficiency anemia.
Falls.
Alcohol use.
Chronic obstructive pulmonary disease.
Bipolar disorder.
Congenital anomalies.
Osteoarthritis.
Schizophrenia.
OCD.
What is Not OCD?
• Pathological gambling.
• Kleptomania.
• Substance abuse disorders.
• Certain sexual behaviors.
– Thoughts are not unwanted.
– Derive pleasure from “compulsive” act.
– Typically, only want to stop because of negative
consequences of acts.
What is Not OCD? (continued)
• Obsessive-Compulsive Personality Disorder (OCPD).
– Collection of personality traits.
– Preoccupation with orderliness, control, rigidity, and
inflexibility (rules, lists, schedules)
– Does not involve obsessions or compulsions.
– May like.
OCD-Spectrum Disorders
• Broader than “OC-related disorders”.
• High degree of symptom overlap.
• High rate of comorbidity.
• Family History.
• Treatment overlap.
– Common underlying neurobiological mechanisms?
OCD-Spectrum Disorders (continued)
• Trichotillomania (hair pulling disorder).
– Recurrent pulling out of one’s hair.
– May play with, chew on, or ingest.
– May nail bite and skin pick.
• No obsessions nor rules that have to be applied
rigidly.
OCD-Spectrum Disorders (continued)
• Body Dysmorphic Disorder (BDD).
– Preoccupation with an imaged or exaggerated defect in
physical appearance (e.g., nose is too big).
• BDD within Eating Disorders
– One could say Eating Disorders are part of the “spectrum”
but they are categorized separately in the DSM system and
always have been.
OCD-Spectrum Disorders (continued)
• Eating Disorders.
– Anorexia Nervosa (Refusal to maintain normal body
weight).
– Bulimia Nervosa (Repeated episodes of binge eating
followed by inappropriate compensatory behaviors (e.g.,
excessive exercise).
– Disturbance in perception of body shape and weight.
Does Genetics Play a Role?
• 20% of first-degree relatives will have OCD.
• Additional 15% will have “subclinical” symptoms.
• Does not appear to be learned (phenotypes different).
Summary
• OCD is a common and debilitating condition.
• Key element of effective treatment is Exposure and
Response Prevention (ERP).
• Keys to effective exposure therapy include prolonged,
repetitive and graduated exposure.
Trauma- and Stressor-Related Disorders
• New Chapter in DSM-5, not just in Anxiety Disorders
chapter
• Includes conditions other than PTSD and Acute
Stress Disorder (DSM-IV), a.k.a. “psychological
shock”
– Reactive Attachment Disorder
– All of the Adjustment Disorders (moved into this chapter)
PTSD Criteria in DSM-5
A. The person was exposed to the following event(s):
death or threatened death, actual or threatened
serious injury, or actual or threatened sexual
violation, in one or more of the following ways:
1. Experiencing the event(s) him/herself
2. Witnessing, in person, the event(s) as they occurred to
others
PTSD Criteria in DSM-5
3. Learning that the event(s) occurred to a close relative or
close friend; in such cases the actual or threatened death
must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive
details of the event(s) (e.g., first responders collecting body
parts; police officers repeatedly exposed to details of child
abuse); this does not apply to exposure through electronic
media, television, movies or pictures unless this exposure
is work-related.
PTSD Criteria in DSM-5
B. Re-experiencing symptoms (recurrent
memories/dreams/nightmares, flashbacks, physical
re-experiencing, high anxiety)
C. Persistent avoidance of stimuli associated with the
trauma (internal cues and external cues)
D. Negative alterations in cognitions and mood that are
associated with the traumatic event (inability to
remember, exaggerated negative beliefs, blaming
self, negative emotional state, emotional numbing,
diminished interests, detachment from others, inability
to love or enjoy)
PTSD Criteria in DSM-5
E. Alterations in arousal and reactivity that are
associated with the traumatic event (irritable,
reckless, hypervigilence, heightened startle,
decreased concentration, sleep disturbance)
F. Duration of the disturbance is more than one month
G. The disturbance causes clinically significant distress
or impairment in social, occupational, or other
important areas of functioning
More Detail on Criterion D.
Negative Cognitions & Mood
1. inability to remember important aspects of the event
(“dissociative amnesia”)
2. Persistent and exaggerated negative expectations and beliefs
about oneself, others or the world (e.g. “I am bad,” “No one
can be trusted,” “My whole nervous system is permanently
ruined,” “The world is completely dangerous” (C7)
3. Persistent distorted blame of self or others about the cause or
consequences of the traumatic event (e.g. self-blame) (NEW)
4. Persistent negative emotional state (for example: fear, horror,
anger, guilt, or shame) (NEW)
More Detail on Criterion E.
Alterations in Arousal & Reactivity
1. Irritable or aggressive behavior (e.g. yelling at other people,
getting into fights or destroying things (revised D3)
2. Reckless or self-destructive behavior (e.g. driving too fast or
while intoxicated, heavy drug or alcohol use, risky sexual
behavior, or trying to injure or harm oneself). (NEW)
3. Hypervigilance
4. Exaggerated startle response.
5. Trouble with concentration.
6. Trouble with sleep onset, staying asleep, or restlessness
during sleep
DSM-5: Acute Stress Disorder
A. PTSD “Criterion A” (sub-criteria 1, 2, 3, 4)
B. No mandatory (e.g., dissociative, etc.) symptoms from
any cluster
C. Nine (or more) of the following 14 items (with onset or
exacerbation after the traumatic event):
– Intrusion Symptoms (4)
– Negative Mood (1)
– Dissociative Symptoms (2)
– Avoidance Symptoms (2)
– Arousal Symptoms(5)
Are we Dealing with Horses or Zebras?
• Common conditions
• Common presentations
• Uncommon conditions
• Uncommon presentations
www.publichealth.va.gov
• Epidemiology is the study of health in populations to
understand the causes and patterns of health and
illness.
Epidemiology
(per the World Health Organization)
The study of the distribution and
determinants of health-related states or
events (including disease), and the
application of this study to the control of
diseases and other health problems.
Epidemiology
The branch of medical science that
investigates all the factors that determine
the presence or absence of diseases and
disorders.
Terms in Epidemiology
• Incidence: The number of new cases of a disease or
disorder in a population over a period of time.
• Prevalence: The number of existing cases of a
disease in a population at a given time.
• Burden of disease: The total significance of disease
for society, beyond the immediate cost of treatment. It
is measured in years of life lost to ill health, or the
difference between total life expectancy and
disability-adjusted life expectancy (DALY).
(Adapted from the World Health Organization.)
Sources of Epidemiological Data
• ECA (Epidemiologic Catchment Area) Study--1980’s
i.e., DSM-III criteria used
• NCS (National Comorbidity Study)—1994
i.e., DSM-III-R criteria used
• NCS-R (NCS-Replication)—2003
i.e., DSM-IV criteria used
• NESARC (National Epidemiologic Survey on Alcohol and
Related Conditions Comorbidity) Study — 2005
Data from NCS-R
• Among all Axis I Mental Disorders, the most common are
ANXIETY DISORDERS (18% -- 12-month prevalence)
and MOOD DISORDERS (9.5%) and SUBSTANCE USE
DISORDERS.
• Anxiety Disorders:
– Social Anxiety (12-month prevalence) = 6.8%
– Specific Phobia (12-month prevalence) = 8.7%
Kessler RC, et al. Archives of General Psychiatry, 62(6):617-27, 2005
Prevalence and Co-occurrence of
Substance Use Disorders and
Independent Mood and Anxiety
Disorders: Results from the NESARC
Grant BF, et al. Archives of General Psychiatry 61:807-16, 2004.
National Epidemiologic Survey on Alcohol
and Related Conditions
• Anxiety disorders occur in 18% to 28% of the US
general population during any 12-month period.
• In anxiety disorder, there is a 33% to 45% 12-month
prevalence rate for a comorbid substance use
disorder (SUD)
• For patients with generalized anxiety disorder (GAD),
the lifetime prevalence of comorbid alcohol abuse
and dependence is 30% to 35%, and the prevalence
of drug abuse and dependence is 25% to 30%.
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
• Among individuals with SUDs, independent DSM-IV
diagnoses of mood or anxiety disorders can be made
in 2 ways.
– First, the full mood or anxiety syndrome is established
before substance use.
– Second, the mood or anxiety syndrome persists for more
than 4 weeks after the cessation of intoxication or
withdrawal.
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
12-month prevalence:
• Any SUD = 9.35%
• Rates of “Substance Abuse” a bit higher than rate of
“Substance Dependence”
• Alcohol Use Disorder (DSM-IV abuse or dependence) =
8.46%
• Drug Use Disorder (DSM-IV abuse or dependence) =
2.00%
– Cannabis Use Disorder = 1.45%
– Opioid Use Disorder = 0.35%
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
• Anxiety Disorders are more strongly associated with
Substance Dependence than with “Drug Abuse”
• Among Anxiety Disorders, Panic Disorder with
Agoraphobia was mot strongly associated with
Substance Use Disorders
• Of those with Any SUD, 17.7% had at least one
independent Anxiety Disorder
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
Alcohol Dependence:
– GAD (Generalized Anxiety) 5.69%
– Social Anxiety 6.25%
– Panic Disorder (combined w/ and w/o agoraphobia) 6.54%
– Specific Phobia 13.84%
• Drug Dependence:
– GAD (Generalized Anxiety) 17.22%
– Social Anxiety 12.91%
– Panic Disorder (combined w/ and w/o agoraphobia) 15.63%
– Specific Phobia 22.26%
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
Treatment Seeking:
• Among those with any independent anxiety disorder in a 12month period, 12.1% sought professional help
• Among those with any independent mood disorder in a 12month period, 25.8% sought professional help
• Among those with an alcohol use disorder in a 12-month
period, 5.8% sought professional help
• Among those with a drug use disorder in a 12-month period,
13.1% sought professional help
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
“Dual Diagnosis” among treatment seekers:
• Among those with GAD in the past 12 months who sought
treatment for it, 15.9% had SUD
• Among those with Social Anxiety Disorder in the past 12 months
who sought treatment for it, 21.3% had SUD
• Among those with Panic Disorder in the past 12 months who
sought treatment for it, 15.4-21.9% had SUD
• Among those with Specific Phobia in the past 12 months who
sought treatment for it, 16.0% had SUD
• Among those with Any Independent Anxiety Disorder in the past
12 months who sought treatment for it, 16.5% had SUD
– By roughly 2:1, more of these people had Alcohol Use Disorder than Drug
Use Disorder
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
“Dual Diagnosis” among treatment seekers:
• Among those with Alcohol Use Disorder in the past 12 months (5.8% of those
surveyed in NESARC), the rates of Anxiety Disorders are high:
– GAD = 12.35%
– Social Anxiety Disorder = 8.49%
– Panic Disorder = 4.1 - 9.1%
– Specific Phobia = 17.24%
– Any Anxiety Disorder = 33.38%
• Among those with Drug Use Disorder in the past 12 months (13.1% of those
surveyed in NESARC), the rates of Anxiety Disorders are high:
– GAD = 22.07%
– Social Anxiety Disorder = 12.09%
– Panic Disorder = 5.9 – 8.6%
– Specific Phobia = 22.52%
– Any Anxiety Disorder = 42.63%
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
– About 18% of all persons in the general population who
have a current SUD have a current independent Anxiety
Disorder of some type
– About 15% of individuals with at least one 12-month
independent Anxiety Disorder have a Substance Use
Disorder
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
– The prevalence of substance-induced anxiety disorder was
about 1% of the general population
“These results strongly suggest that treatment for mood or
anxiety disorder should not be withheld from those with
substance use disorders in stable remission on the
assumption that most of these disorders are due to
intoxication or withdrawal” (i.e., are “substance-induced”
conditions).
Grant BF, et al. Archives of General
Psychiatry 61:807-16, 2004.
“Taken together, the NESARC results provide clear
and persuasive evidence that mood and anxiety
disorders must be addressed by alcohol and drug
treatment specialists, and that substance use
disorders must be addressed by primary care
physicians and mental health treatment specialists.”
E. Jane-Llopis & I. Matytsina. Drug and
Alcohol Review 25:515-35, 2006
“Co-occurrence of current Substance Use Disorders and
personality disorders were pervasive in the US
population. Up to 39% of those with alcohol
dependence and up to 69% of those with drug
dependence had a comorbid personality disorder of any
type.”
(citing B.F. Grant, et al, Archives of General Psychiatry
61:361-68, 2004)
[WHO Regional Office for Europe]
E. Jane-Llopis & I. Matytsina. Drug and
Alcohol Review 25:515-35, 2006
The International Consortium in Psychiatric
Epidemiology study, based on six large epidemiological
studies, identified that, on average, 25% of those cases
of [alcohol abuse] and 32% of those cases of alcohol
dependence had a lifetime history of anxiety disorder.
[WHO Regional Office for Europe]
E. Jane-Llopis & I. Matytsina. Drug and
Alcohol Review 25:515-35, 2006
It is more likely for people with alcohol dependence or
drug dependence to suffer from a comorbid mental
disorder than vice versa.
“The evidence for the onset of anxiety disorders after a
substance use disorder is less strong, and the available
evidence points towards the opposite direction.”
[WHO Regional Office for Europe]
Addiction and Anxiety
How do you treat
Addiction?
Treatment of Addiction
Specialty Treatment
Levels of Care (ASAM PPC)
•
•
•
•
General Outpatient
Intensive Outpatient/Day Treatment
Residential
Hospital
Components of Comprehensive Drug Abuse Treatment
Child Care
Services
Family
Services
Vocational
Services
Intake Processing /
Assessment
Housing /
Transportation
Services
Behavioral
Therapy and
Counseling
Clinical and Case
Management
Financial
Services
Treatment Plan
Substance Use
Monitoring
Pharmacotherapy
Self-Help / Peer
Support Groups
Mental Health
Services
Medical
Services
Continuing Care
Legal
Services
AIDS / HIV
Services
Educational
Services
Treatment of Addiction
• Abstinence is the standard treatment goal for
addiction
• Treatment includes
– Psychosocial Rehabilitation
• (various methods of counseling/psychotherapy)
– Pharmacotherapy
– Self-Help as an adjunct
Non-Pharmacological Tx
•
•
•
•
•
•
•
•
•
•
•
Addiction Counseling (supportive / RET / confrontational)
Cognitive Behavioral Therapy (CBT)
Coping Skills Training
Recreational Therapy
Psychoanalytically-oriented Psychotherapy
Motivational Enhancement Therapy (MET)
Community Reinforcement Approach (CRAFT)
Twelve-Step Facilitation (TSF)
Network Therapy
Behavioral Therapy
Aversion Therapy
Standard Treatment Components
• Milieu therapy
• General alcoholism counseling
• Educational lectures and films
• Introduction to and Referral to Alcoholics Anonymous
Targeted Therapeutic Changes in
Addiction Treatment
BEHAVIORAL CHANGES
BIOLOGICAL CHANGES
• Eliminate alcohol and other drug
use behaviors
• Eliminate other problematic
behaviors
• Expand repertoire of healthy
behaviors
• Develop alternative behaviors
• Identify triggers for using
behaviors/relapses
• Resolve acute alcohol and other
drug withdrawal symptoms
• Physically stabilize the organism
• Develop sense of personal
responsibility for wellness
• Initiate health promotion
activities (e.g., diet, exercise,
safe sex, sober sex)
• Address cravings through
medical interventions (treatment
medications)
Targeted Therapeutic Changes in
Addiction Treatment
COGNITIVE CHANGES
AFFECTIVE CHANGES
• Increase awareness of illness
• Increase awareness of negative
consequences of use
• Increase awareness of addictive
disease in self
• Decrease denial
• Increase emotional awareness
of negative consequences of
use
• Increase ability to tolerate
feelings without defenses
• Manage anxiety and depression
• Manage shame and guilt
Targeted Therapeutic Changes in
Addiction Treatment
SOCIAL CHANGES
SPIRITUAL CHANGES
• Increase personal responsibility
in all areas of life
• Increase reliability and
trustworthiness
• Become resocialized:
reestablished sober social
network
• Increase social coping skills:
with spouse/partner, with
colleagues, with neighbors, with
strangers
• Increase self-love/esteem;
decrease self-loathing
• Reestablish personal values
• Enhance connectedness
• Increase appreciation of
transcendence
Taken from: Miller, Michael M. Principles of
Addiction Medicine, 1994; published by
American Society of Addiction Medicine, Chevy
Chase, MD
Evidence Based Psychotherapies
• Twelve-Step Facilitation (not just “go to A.A.”)
– Explain/educate
– Promote attendance/participation
– Explore experiences: Attendance? Participation?
Barriers?
– Reflect, process, problem-solve
– Working the Steps
– Working with a Sponsor
What can AA do for you?
Follow the Steps
1. We admitted we were powerless
over alcohol—that our lives had
become unmanageable.
2. Came to believe that a Power
greater than ourselves could
restore us to sanity.
3. Made a decision to turn our will and
our lives over…
4 .Made a searching and fearless
moral inventory of ourselves.
5. Admitted the exact nature of our
wrongs (and stated this openly to
another human begin)
6. Were entirely ready to have…all
these defects of character [removed].
7. [Humbly asked to have these
shortcomings removed ].
8. Made a list of all persons we had
harmed, and became willing to make
amends to them all.
9. Made direct amends to such people
wherever possible, except when to do
so would injure them or others.
AA Meetings
• Types
– Open
– Closed
• Structure
– Speaker meeting
– Discussion meeting
– Step meeting
– Big Book meeting
– Beginners’ meeting
– Couples meetings
– ‘Professionals meetings’ / Caduceus
Underlying Premises of AA
1. The primary goal of AA is to help people achieve longterm abstinence through mutual self-help groups.
2. Alcoholism is a medical disease, not a moral deficiency.
3. Alcoholism is a progressive, often fatal, condition with
exacerbations and remissions that can be arrested but
not cured.
4. Lifelong abstinence is necessary for long term recovery
5. Recovery involves addressing the physical, emotional
and spiritual problems associated with alcoholism.
6. Recovery is a long term process, not a single event.
Evidence Based Psychotherapies
• Twelve-Step Facilitation (TSF)
• Motivational Enhancement Therapy (MET)
• Cognitive Behavioral Therapy (CBT)
• Contingency Management
MET (Motivational Enhancement Therapy)
• What concerns you?
• What are you using?
• Do you see a problem, a link?
• Help patient see the problem, the link.
• Get them to start contemplating the issue, gradually
move them to start contemplating change, to begin
planning for change…
Readiness for Change
Stages of Change
•
•
•
•
•
Precontemplative
Contemplative
Preparation
Action
Maintenance
MOTIVATIONAL ENHANCEMENT THERAPY moves the
person along the stages of change….
Motivational Interviewing (M.I.)
• Identify what the patient wants
• Identify what you want
• Try to get the patient’s goals and the therapist’s goals
to align
General Principles of M.I.
• Express Empathy: this guides therapists to share
with clients their understanding of the clients'
perspective.
• Develop Discrepancy: this guides therapists to help
clients appreciate the value of change by exploring
the discrepancy between how clients want their lives
to be vs. how they currently are (or between their
deeply-held values and their day-to-day behavior).
General Principles of M.I.
• Roll with Resistance: this guides therapists to
accept client reluctance to change as natural rather
than as pathological.
• Support Self-efficacy: this guides therapists to
explicitly embrace client autonomy (even when clients
choose to not change) and help clients move toward
change successfully and with confidence.
Motivational Interviewing:
Advantages of Change
(Start with Rogerian self-regard — empathetically engage
around their current situation and how they feel about it)
How would you like for things to be different?
What would be the good things about losing weight?
What would you like your life to be like 5 years from now?
If you could make this change immediately, by magic, how
might things be better for you?
• The fact that you’re here indicates that at least part of you
thinks it’s time to do something. What are the main reasons
you see for making a change?
• What would be the advantages of making this change?
•
•
•
•
Motivational Interviewing:
Disadvantages of the status quo
(Develop Discrepancy: increase their cognitive dissonance
about staying where they are)
• What worries you about your current situation?
• What makes you think that you need to do something about
your blood pressure?
• What hassles have you had in relation to your drug use?
• What is there about your drinking that you or other people
might see as reasons for concern?
• In what way does this concern you?
• How has this stopped you form doing what you want to do in
life?
• What do you think will happen if you don’t change anything?
Motivational Interviewing:
Optimism about change
• What makes you think that if you did decide to make a
change, you could do it?
• What encourages you that you can change if you want to?
• What do you think would work for you, if you decided to
change?
• When else in your life have you made a significant change like
this? How did you do it?
• How confident are you that you can make this change?
• What personal strengths do you have that will help you
succeed?
• Who could offer you helpful support in making this change?
Motivational Interviewing:
Intention to change
• What are you thinking about your gambling at this point?
• I can see that you’re feeling stuck at the moment. What is going
to have to change?
• What do you think you might do?
• How important is this to you to lose weight? How much do you
want to do this?
• What would you be willing to try?
• Of the options I’ve mentioned, which one sounds like it fits you
best?
• Never mind the “how” for right now – what do you want to have
happen?
• So what do you intend to do?
Principles of CBT
• Thoughts
• Behaviors
• Emotions
• Other lingo = ABC (Affect, Behaviors, Cognitions)
• If you’re depressed or anxious, it could relate to what
you think/believe, and what you’re doing
• DO IT DIFFERENTLY
• RE-THINK IT
CBT
• Behavioral Journals/Logs
• Thought Journals/Logs
• Feelings Journals/Logs
Thought Challenging (irrational/un-useful T’s)
Cognitive Reframing
Behavior Change: Do It Different!
Do things that make you feel successful/happy.
www.drugabuse.gov
NIDA Principles of Drug Addiction Treatment
(1999, rev 2009)
1. Addiction is a complex but treatable disease that
affects brain function and behavior. Drugs of abuse
alter the brain’s structure and function, resulting in
changes that persist long after drug use has ceased.
2. No single treatment is appropriate for everyone.
NIH Publication No. 09–4180
The ASAM Criteria
and ASAM Criteria Software
The ASAM Criteria
• Intensity of Service should derive from
Severity of Illness
• Treatment should follow multidimensional
Assessment
• Diagnosis—Treatment Plan—
Determination of Level of Care
Assessment Dimensions
• Intoxication/Withdrawal Potential
• Biomedical Conditions/Complications
• Emotional/Behavioral/Cognitive Conditions
• Treatment Acceptance/Readiness/Motivation
• Relapse/Continued Use Potential
• Recovery Environment
Levels of Care
• 0.5 Screening/Brief Intervention/Education
• 1.0 General Outpatient
• 2.0 Intensive Outpatient/Partial Hospital
• 3.0 Medically Monitored/Residential
– halfway houses, extended care, TC’s
• 4.0 Medically Managed/Inpatient
• In some cases of addiction, medication management
can improve treatment outcomes.
• In most cases of addiction, the integration of
psychosocial rehabilitation and ongoing care with
evidence-based pharmacological therapy provides the
best results.
• Chronic disease management is important for
minimization of episodes of relapse and their impact.
• Treatment of addiction saves lives
Using DRUGS to treat Drug Addiction
Addiction
• Nicotine—pharmacotherapy is available
• Opioids—pharmacotherapy is available
• Alcohol—pharmacotherapy is available
• Sedatives
• Stimulants
• Cannabinoids
• Hallucinogens
• Inhalants
• Gambling
Overview of Pharmacotherapies
for Addiction
• Antabuse—for alcohol addiction
• Naltrexone, acamprosate, gabapentin, topiramate, et
al.—for alcohol addiction
• Naltrexone—for opioid addiction
• Opioid Agonist Therapies—MMT
• O.B.O.T.—buprenorphine
• N.R.T., bupropion, varenicline—for nicotine addiction
Addiction and Anxiety
How do you treat Anxiety?
How do you treat Anxiety?
• Psychotherapy
• Pharmacotherapy
• Complimentary/Alternative Medicine
Treatment of Anxiety Disorders
• Pharmacotherapy
• Supportive Therapy
• Psychoanalytically-oriented Psychotherapy
• Behavioral Therapy (ERP)
• Cognitive Behavioral Therapy
– A. Timothy Beck, PhD., University of Pennsylvania
– “Cognitive Therapy of Depression”, 1979
– Broad applicability/utility: depression, anxiety, phobias,
addiction, OCD, eating disorders
Bradley C. Riemann, PhD
Clinical Director, OCD Center and
Cognitive Behavioral Therapy Services
Principles of CBT
• Thoughts
• Behaviors
• Emotions
• Other lingo = ABC (Affect, Behaviors, Cognitions)
• If you’re depressed or anxious, it could relate to what
you think/believe, and what you’re doing
• DO IT DIFFERENTLY
• RE-THINK IT
CBT
• Behavioral Journals/Logs
• Thought Journals/Logs
• Feelings Journals/Logs
Thought Challenging (irrational/un-useful T’s)
Cognitive Reframing
Behavior Change: Do It Different!
Do things that make you feel successful/happy.
Pharmacotherapy for Anxiety
• Benzodiazepines
• Other sedative-hypnotics
• Other agents
– buspirone (BuSpar®)
– Antihistamines (Benadryl®)
– clonidine
– gabapentin
– atypical antipsychotics
– beta-blockers (propranolol, atenolol)
Pharmacotherapy for Anxiety
• NO TO Benzodiazepines
• Serotonin drugs
– SSRI
– SNRI
– Tricyclic antidepressants (TCADs)
– MAOIs
• Bupropion (Wellbutrin®)
Medications
Advantages:
•
•
•
•
Easy to do.
Effective.
Safe long-term.
Accessible.
Disadvantages:
• Potential side effects.
– Anafranil (constipation, blurred
vision, sedation, tremor).
– Others (insomnia, agitation, nausea,
sexual)
• Do not act quickly.
• Rarely eliminates symptoms
(expect 30%).
• High relapse rates (80% in 7-12
weeks).
• Noncompliance
Behavior Therapy (BT)
• Exposure and Response/Ritual Prevention (ERP) is
the key element.
– Meyer (1966).
– Based on the principle of habituation.
– Habituation is the decrease in anxiety experienced with the
passage of time.
Behavior Therapy (continued)
• Exposure is placing an individual in feared situations
(targets the obsessions).
– Needs to be prolonged enough to lead to within trial
habituation (at least 50% reduction in anxiety).
– Needs to be repetitive enough to lead to between trial
habituation (until causes minimal to no anxiety).
– Needs to be graduated (increases compliance).
Types of Exposures
• Imaginal exposure.
– Conduct exposure in imagination.
– Conduct exposure with electronically recorded scenerios.
• In vivo Exposure.
– Real-life exposure.
– Typically more effective.
– Go out into the community.
– Imaginal approach is important when in vivo is determined
to be impractical, dangerous, or anxiety-unmanageable.
Types of Exposures (continued)
• Self-Exposure.
– Conducted by patient alone.
• Therapist-Aided Exposure.
– Both therapist and patient perform or while therapist is
present.
Behavior Therapy (continued)
• Ritual Prevention is blocking the typical response or
ritual before, during, and after exposure so
habituation can take place (targets compulsions).
– Replace the ritual with habituation as way of controlling
anxiety.
Treatment Steps
• Assessment Phase.
– Initial evaluation (1 hour).
– Confirm diagnosis.
– Identify problem areas (e.g., door knobs).
– Assess for comorbid diagnoses.
– Educate patient and family about the patient’s specific
diagnosis, and treatment options.
Cognitive Restructuring
• Used as an addition to ERP.
• Global targets.
– Increasing tolerance of uncertainty.
– Decreasing perceived need to control thoughts
(e.g., suppression of unwanted thoughts).
– Decreasing the perceived importance of thoughts.
Cognitive Restructuring
• Specific targets.
– Attempts to identify and correct “errors” in thinking.
• Probability Overestimation Errors (e.g., contracting AIDS from
not washing hands).
• Catastrophizing Errors (e.g., checkout person not groomed
well).
Effectiveness of ERP
• 97% of patients experience habituation with ERP.
• Foa (1996) meta-analysis of 12 studies with 330
patients.
– 83% much or very much improved.
• Greist (1996) compared 18 studies with 294 patients.
– Average decrease in YBOCS of 11.8 (SRI’s=7.5).
Effectiveness of ERP (continued)
• Low relapse rates with ERP.
– Foa (1996) 16 studies with 376 patients found 76% much or very much
improved at follow-up (average 2.5 years).
• 50% of “medication relapsers” can discontinue SRI’s
if add ERP.
• Many believe ERP is “first-line” treatment.
Effectiveness of Rogers’ IOP
• Adults.
– Admitting Y-BOCS
25.9
– Discharge Y-BOCS
13.7 (-47.1%)
– Admitting BDI-2
25.7
– Discharge BDI-2
11.2 (-56.4%)
Residential Treatment at Rogers
• Kids.
– Admitting CY-BOCS
– Discharge CY-BOCS
– Admitting CDI
– Discharge CDI
22.0
8.2 (-62.7%)
11.3
6.3 (-44.3%)
Residential Treatment at Rogers
• Adolescents.
– Admitting CY-BOCS
26.1
– Discharge CY-BOCS
13.6 (-47.8%)
– Admitting BDI-2
20.4
– Discharge BDI-2
8.0 (-60.6%)
Residential Treatment at Rogers
• Adults.
– Admitting Y-BOCS
28.4
– Discharge Y-BOCS
16.5 (-41.9%)
– Admitting BDI-2
28.8
– Discharge BDI-2
12.6 (-56.2%)
Co-Morbid Program at Rogers
• Adults
– Admitting Y-BOCS
24.6
– Discharge Y-BOCS
13.3 (-45.9%)
– Admitting BDI-2
32.6
– Discharge BDI-2
15.4 (-52.8%)
Oconomowoc
Residential Centers
Child & Adolescent Centers
Charles E. Kubly FOCUS Center
Nashotah Program
OCD Center at Cedar Ridge
Herrington Recovery Center
Eating Disorder Center
Advantages of ERP
• Effective and robust.
• “Only” side effect is increased anxiety during
treatment (can manage by conducting graduated
exposure).
• Quick improvements (many after first week of
treatment).
Disadvantages of ERP
• Hard work.
• Noncompliance.
• Absence of ERP.
• Quality of ERP when available.
Treatment for Posttraumatic
Stress Disorder (PTSD)
Chad Wetterneck, PhD
Clinical Supervisor and Cognitive Behavior Specialist
Posttraumatic Stress Disorder Programs
PTSD Program Locations:
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Oconomowoc
Milwaukee (West Allis)
Brown Deer
Regional
Residential
Trauma & Risk of PTSD
• Epidemiology
– 39% of adults have
experienced a
traumatic stressor
• 25% of these later
develop PTSD
• Rape more likely to
cause PTSD than injury
or accident
– Lifetime prevalence is
10% for women and
5% for men
Common Reactions to Trauma
• Fear and anxiety
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•
Re-experiencing the trauma
Flashbacks
Nightmares
intrusive memories
Trouble concentrating
Hypervigilance (hyperarousal, over-alertness, startle)
Irritability, “jumpiness,” anger
Emotional numbing
Dissociative symptoms
Feeling like “going crazy”
Common Reactions to Trauma
•
•
•
•
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•
•
Avoidance (of trauma reminders; generalized avoidance)
Feeling cut-off from others or isolated
Feelings of a foreshortened future
Guilt
Shame
Poor self image
Loss of interests, depression
Worthlessness/hopelessness
Hopelessness/giving up/death ideas
Posttraumatic Stress Disorder (PTSD)
• Most people recover from a trauma on their own
• Some people continue to feel traumatized long after
the event
• When symptoms of trauma last more than 1 month, a
person may be diagnosed with PTSD
• When symptoms last a year, they are unlikely to get
better on their own
• Any change can be traumatizing
When Professional Help is Needed
• Trauma symptoms are getting
worse or just not getting better
• The traumatized person needs
substances to cope with life
• The traumatized person
becomes depressed or suicidal
Shame & Secrecy
• Feelings of helplessness lead to shame
• Shame leads to secrecy
• Secrecy is BAD…. Why?
– prevents “talking about it” (talking leads to natural healing)
– prevents others from being supportive (leading to isolation)
– prevents thinking about the trauma in new ways and
emotional growth (processing)
Treating the PTSD (1)
Psychotherapists who specialize in PTSD suggest some
general principles for the psychological treatment:
1. establishing a trusting therapeutic relationship,
2. providing education about the process of coping with
trauma,
3. stress-management training,
4. encouraging the re-experience of the trauma, and
5. integrating the traumatic event into the individual’s
experience.
PTSD: Psychotherapy (CBT)
• Stress Inoculation Training
– Education about trauma
– Anxiety management strategies (e.g., controlled breathing,
cognitive restructuring)
– Collaboratively select strategies and practice implementation
• Cognitive Therapy
– ID trauma-related beliefs linked to emotional and behavioral
responses
– Evaluate thoughts more logically
– Determine if beliefs reflect reality, and if not, modify it
Williams et al. (2012)
PTSD: Psychotherapy (EMDR)
• Eye Movement Desensitization and Reprocessing
– Generate images/thoughts about trauma
– Evaluate aversive qualities
– Alternative cognitive appraisal while person follows the
therapists finger with eyes
Williams et al. (2012)
PTSD: Non-CBT Approaches
• Psychodynamic therapy
– Expressive therapy
– Supportive therapy
– Psychodynamic-integrative therapy
 Effectiveness: Needs empirical support
• Group Therapies
– Utility: (1) combat feelings of isolation (2) mutuality
– Type
• Supportive, psychodynamic, and cognitive-behavioral
• Overall goal: create a “safe” place
 Effectiveness: Needs empirical support
(Williams et al., 2012)
Why Exposure Based Treatments?
• Exposure-based treatment approaches have been
shown to be effective
• Prolonged exposure has the most support in the
research literature for the treatment of trauma
– The traumatized person revisits the trauma in their
imagination with a supportive counselor
– The traumatized person stops avoiding
Prolonged Exposure Can Prevent PTSD in
Immediate Trauma Survivors
Rothbaum et al. (2012)
Factors Influencing Treatment Outcome
• Pre-treatment variables = poorer outcomes
– Trauma related
• Hx of childhood trauma; Multiple traumas ; Personal vs. impersonal
trauma; Time since trauma; Whether injured during trauma
– Personal characteristic
• Male gender; Suicidal; Living alone; Comorbid GAD/depression; Anger
problems
• General treatment variable = poorer outcomes
– Low credibility of tx; low motivation of patient; low patient
engagement; less completed homework
(Williams et al., 2012)
Breathing Retraining
• The way we breathe affects the way we feel
• Exhalation, not inhalation, is associated with relaxation
• Slow down your breathing to avoid hyperventilation
• Concentrate on slow exhalation while saying CALM (or
RELAX) to yourself
• Pause and count to 4 before taking second breath
• The therapist makes a 3-minute recording of his/her voice
leading the patient through the breathing exercise
Rationale for the Treatment
• The program focuses on addressing trauma related
fears and symptoms.
• Three main factors prolong post-trauma problems:
– Avoidance of trauma related situations (e.g., sleeping with
a light on, not going out alone)
– Avoidance of trauma-related thoughts
– The presence of dysfunctional cognition: “The world is
extremely dangerous”, “I am extremely incompetent.”
Rationale for the Treatment
• The avoidance strategies prevent the patient from
processing the trauma, from modifying the
dysfunctional cognitions (e.g., trauma reminders are
not dangerous).
Rationale for the Treatment
• The two main procedures are:
– Imaginal exposure is repeated reliving of the traumatic
event. Confrontation with painful experiences enhances
the processing of these experiences and modifies
dysfunctional cognitions.
– In vivo exposure is repeatedly approaching trauma
related situations that are avoided since the trauma. In
vivo exposure is very effective in reducing excessive fear
and unnecessary avoidance. It enables the patient to
realize that these situations are not dangerous, thus
modifying dysfunctional cognition.
Factiliating Therapeutic Alliance
• Praise patient for coming to treatment and acknowledge courage
• Communicate understanding of the patient’s symptoms
– Incorporate examples in treatment descriptions (e.g., common reactions)
• Validate patient’s experience and be non-judgmental
– May be the first time relating the trauma narrative, your reaction is
important
– Normalize and validate the response to trauma and what the patient did for
“survival” after the event
• Early behavioral responses to current dysfunctional schemas may have served
an important purpose
• Work collaboratively
– incorporate the patient’s judgment regarding pace and targets of therapy
Rationale for Imaginal Exposure:
Revisiting the Trauma
• Repeated revisiting:
– Helps process (digest) the trauma, i.e., organize, make
sense of it, “file it in the right drawer”
– Results in habituation, so that the trauma can be
remembered without intense, disruptive anxiety
– Helps distinguishing between “thinking” about the trauma
and actually “re-encountering” it.
– Fosters the realization that engaging in the trauma memory
does not result in loss of control or “going crazy”
– Enhances sense of self control and personal competence
Implementing Imaginal Exposure
• Recall the memory as vividly as possible
• Imagine that the trauma is happening now
• Stay in touch with the feelings that the memory elicits
• Describe the trauma in present tense
• Recount as many details as you can
• Include details of the event, thoughts, and feelings
• Homework:
– Listen to recordings of the imaginal exposure once a day and
revisit the trauma
Therapist-Patient Alliance During Revisiting
• Express support and empathy with patient’s distress
• Periodically reassure patient that he/she is safe (e.g., “I
know this is tough; you are doing a good job staying with it”)
• Titrate patient’s emotional response:
– Probe for thoughts and feelings to encourage emotional
engagement
– If patient becomes overwhelmed with distress, conduct exposure
with patient’s eyes open
• Allow sufficient time after exposure to discuss and process
experience and calm patient as needed
Rationale for In Vivo Exposure
• Trauma related fears are often unrealistic or excessive
(e.g., going to a shopping mall).
• Repeated in vivo exposure
– Blocks negative reinforcement
– Results in habituation, so that the target situation becomes
increasingly less distressing
– Fosters the realization that the avoided situation is quite safe
– Disconfirms the belief that anxiety in the feared situation
continues ‘forever’
– Enhanced sense of self control and personal competence
Implementing In Vivo Exposure
• Present the treatment rationale
• Give daily life examples of in vivo exposure and
habituation
– (e.g., a child fearing being in a pool)
• Develop a list of situations the patient has been
avoiding since the trauma
• Ask patient to rate the intensity of anxiety s/he
experiences when imagining confronting each
situation
Implementing In Vivo Exposure
• Arrange the situations in a hierarchy
• If the patient cannot identify circumstance, suggest
typically avoided situations.
• Inquire about the actual safety of the situations
Implementing In Vivo Exposure
• Homework Assignment
– Begin with assigning exposure to situations that evoke low
to moderate levels of anxiety
– Instruct the patient to remain in each situation for 30 to 45
minutes, or until the anxiety decreases considerably
– Emphasize the importance of remaining in the situation
until symptom level decreases by > 50%
Example of an In Vivo Hierarchy
Feared Situation
SUDS
Staying at home alone in the middle of the day
50
Driving to a friend’s home in a safe neighborhood in daytime
60
Driving to a friend’s home in a safe neighborhood after dark
70
Walking down a street in her parent’s neighborhood
75
Staying alone in her room on the campus with door locked
80
Walking with a friend on campus
85
Walking alone on campus during the daytime
90
Walking on campus at night
100
Addressing Avoidance
• Validate patient’s fear and urges to avoid
• Review the rationale for treatment
• Avoidance reduces anxiety in the short term but in the long
term it prevents learning
• Memories are not dangerous
• Use analogies to support the rationale
• e.g., avoidance is like sitting on a fence, or living in a cave
where the patient retreated to heal from the trauma
Addressing Avoidance
• Review the reasons that the patient sought treatment
for PTSD
• How do PTSD symptoms interfere with life satisfaction?
• Review the progress that patient has already made
• Provide a lot of support, encouragement
• Schedule inter-session phone contact to provide support and
discuss homework progress
• Problem-solve solutions to concrete obstacles to
compliance with therapy
Facilitating Homework Compliance
• Reiterate the rationale
• patient must understand why she is being asked to do
homework
• Find out what is getting in the way:
• Organization (e.g., lost sheet, forgot)
• Practical issues (e.g., no time, no privacy)
• Avoidance
• Intervention guided by nature of the compliance
problems
The Solution to the Clinical Challenges of
Effectively Addressing Addiction and
Anxiety & Related Disorders:
 Integrated Clinical Services
 Knowledgeable/Competent Staff:
• “Dually Licensed”, Ph.D. Supervisors
• Board Certified Physicians (Psychiatry and
Addiction Medicine)
 Psychotherapy and Pharmacotherapy
The Herrington Recovery Center
Rogers Behavioral Health – Tampa Bay
2002 N. Lois Avenue, Suite 400 | Tampa
813-498-6000 | rogersbh.org
Thank you!
800-767-4411
rogershospital.org
Michael M. Miller, MD, FASAM, FAPA
mmiller@rogershospital.org