Dual Diagnosis Case Studies
Mark Holland PhD
Consultant Nurse
Manchester Mental Health & Social Care Trust
14.3.12
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 16
Cluster 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/with
F10 – 19 (Mental & behavioural disorders due to
psychoactive substance use)
Risk :
Overdose (intentional/accidental)
Entry into CJS
Harm to self
Harm to others/From others
Course:
Long term – 3 yrs +
C 16 Expected Needs
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Medication management/pharmacology
Health education/harm minimization
Engagement
Motivational interviewing
Social inclusion
C 16 Partnership working
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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 Needs
CRISIS MANAGEMENT
Management of intoxication
Mental health relapse
CARE COORDINATION
Should be under mental health service CPA
Care coordination by someone experienced (level 3 capability framework)
Drug/alcohol relapse
MONITORING 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
advice
DETOX & REHAB
Access to detox (complex cases capability)
Admission to appropriate complex needs rehabilitation
C16 QUALITY AND OUTCOMES GOALS
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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
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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
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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
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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
Overview
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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
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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
established
change
action
preparation
contemplation
maintenance
relapse
pre-contemplation
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Decisional Balance Sheet
Not Change
Change
Good things
Not so Good
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Importance and confidence
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Readiness to
change
Importance
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Confidence
10
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Preparation - Cognitive Model
Affect
View of past
Self-view
Cognitions
Behaviour
View of future
View of immediate life
situation
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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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Coming up with a ‘Relapse Cycle’ or case formulation
Beliefs
(cannabis is good
for me, need it to
get going, relieve
tension/ anger,
craving)
Trigger/High Risk
Situation
(out, paranoid
feelings anxiety low
mood)
Cravings / positive
anticipation
(physical and psychological –
anticipated positive effect)
Susceptibility
to Triggers
Sequalae
(dissonance- feel
bad / weakened
resolve; relief
short-lived)
Auto Thoughts
(What the hell!
My life has
turned out bad)
Use / lapse
/ relapse
(relief
obtained)
Urge / Focus
on Action
(Score, roll
joint - relief
begins)
Permissive
thoughts
(I deserve not to
suffer this tension,
it’s not my fault)
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Beliefs about substances that contribute to
cravings and urges
BELIEF
Anticipatory
Expectations
(relieforientated)
Permissive
Catastrophic
PROCESS
Assess,
examine and
test out belief
(Socratic
questioning,
guided
discovery)
REPLACEMENT
BELIEFS
MAINTAINING
STRATEGIES
‘Cons’
flashcard
Success
flashcard
Activity
schedule
Supporters /
sponsors
Imagery
It’s not my fault but techniques
I can do something
else
It can improve, this
is a lapse not a
relapse
Not as good as
expected
Temporary relief
only
I used to do good
satisfying things so
I could do them
again
AFFIRMED
REPLACEMENT
BELIEFS
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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Relapse Cycle: Opportunities for Intervention
Beliefs
(good/bad for me,
need a joint to get
going, relieve
tension/ anger,
craving)
Trigger/High Risk
Situation
(out, paranoid
feelings anxiety low
mood)
Susceptibility
to Triggers
Sequalae/
catastrophic
(dissonance- eel
bad / weakened
resolve, it’s getting
worse)
Red – Cognitive
Green - behavioural
Use / lapse
/ relapse
(relief
obtained)
Urge / Focus
on Action
(Score, roll
joint - relief
begins)
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)
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Considering and selecting symptoms
Mood
Cognitive /
thinking
Behavioural
Physiological
Motivational
Antidepressants, CBT, Counselling,
psychotherpay
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 it
Reattribution of responsibility (extrinsic factors to internal
factors – empowerment / self-efficacy)
Activity schedule, relapse prevention suicide
prevention, social skills- assertiveness, vocational,
employment, ‘cons’/ success flash cards, PMR
relaxation
Sleep hygiene, hypnotics, activities, anxiety
management
Pros and cons of current use / behaviour (wishes to33
escape - suicide / drugs), importance & confidence
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 the
thrashing 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
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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