Medical

Comorbidities
of Drug Abuse Psychiatric

Drugs
Learning Objectives:
At the end of the module, the participant should be
able to:
1. identify the most common comorbid or co-
occurring mental disorders.
2. manage patients with dual diagnosis
3. familiarize themselves and identify the different
types of personality disorders among substance
abusers.
4. identify the goals of treatment in addiction and
psychiatry.
Outline of Presentation

 Management of Different Psychiatric

Comorbidities
 Different Terminologies
 Comorbidities with Specific Physical

Disorders
 Management of Patients with Dual

Diagnosis
Outline of Presentation

 Different Types of Personality Disorders

among Substance Abusers
 Goals of Treatment in Addiction and

Psychiatry
It is generally agreed that 50% of the
mentally ill population also has a
substance abuse problem.

National Alliance for the Mentally Ill

National Comorbidity Survey shows:

 41 to 65.5% of those with an addictive

disorder also have at least one mental
disorder
 51% of those with a mental disorder have

at least one addictive disorder

Substance Related Disorders in the following
psychiatric conditions:
 47% of schizophrenic patients
 61% of bipolar patients
Comorbid

 when an individual suffers from a mental

illness in addition to having problems with
substance abuse
Other Terminologies

 Addiction & Co-occurring Disorders (ACD)

 Chemically Abusing Mentally Ill (CAMI)
 Co-occurring Addictive & Mental Disorders

(COAMD)
 Mentally Ill Chemically Addicted (MICA)
 Mentally Ill Substance Abuser (MISA)
Other Terminologies

 Substance Abusing Mentally Ill (SAMI)

 Co-occurring Disorders
 Dual Disorders
Types
Certain mental health issues combine with
substance abuse more than others.
These include:
 Depression
 Anxiety Disorders
 Schizophrenia
 Personality Disorders
Depression, Anxiety Disorders, Schizophrenia

 Since these illnesses are usually treated

with medication in addition to psychosocial
interventions, without a comorbid, the
medications can be dangerous or ineffective
when mixed with the substances that the
patient abuses. This is a major reason to
treat both issues together.
Depression, Anxiety Disorders, Schizophrenia

 Relatively few drug users are entirely free from

other physical or mental health problems.
 Many such problems represent direct

consequences, even of so-called 'recreational'

drug use. Frequent examples are:
◦ mood disturbances after 'ecstasy',
◦ psychotic episodes in stimulant use
◦ respiratory disease due to cannabis
Treatment
 If these illnesses are not treated together, there
is a significantly lower chance of recovery.
 Abstinence from drugs and alcohol may cause

symptoms of the mental illness to be more

noticeable to the individual, which can lead
back to using substances.

*The two issues are so enmeshed that they rely

on each other to exist and make the other one
stronger (worse).
Treatment
 Treatment needs to include
• detoxification
• mental health interventions
• education on alcohol, drugs and relapse
• case management
• community resources
• support groups for mental health and
chemical addiction
Comorbidities with Specific Physical
Disorder

 HIV: transmitted through injection, sexual

means & vertical transmission
 Hepatitis C:

• 60-90% among population of injecting

drug misusers
• chronic liver disease that progress to
cirrhosis and carcinoma
Rehabilitation of Comorbid Patients

 Usually requires pharmacological treatment

coupled with intense therapy and continued
follow-up
 Some straight addiction programs (12 Steps

Program) denounce taking any medication

and can actually cause harm by encouraging
abstinence from mental health medication.
Rehabilitation of Comorbid Patients

 There are comorbid support groups specifically

designed to address this issue (Alliance for the
Mentally Ill; Dual Recovery Group).
 Most drug rehabilitation centers offer comorbid

treatment. Some facilities focus exclusively on

patients that have a comorbid. Consider costs,
location and program reputation when looking
for an appropriate rehab program.
Inclusively

 The National Alliance on Mental Illness

reports that ...
 the addiction and the mental illness should

be treated at the same time for the patient to

have a greater chance of achieving long-
term recovery.
Inclusively

 One of the most common cause of psychiatric

relapse is the abuse of alcohol, marijuana and
psychostimulants.
 The most common cause of relapse to

substance use/abuse is untreated psychiatric

disorder.
Amnestic Syndrome
 Korsakoff’s Syndrome is an amnestic syndrome
caused by thiamine deficiency, most commonly
associated with the poor nutritional habits of
people with chronic alcohol abuse.
Delirium
 Characterized by an acute decline in both the
level of consciousness and cognition with
particular impairment in attention
 A life threatening, yet potentially reversible

disorder of the central nervous system (CNS)

 Often involves perceptual disturbances,

abnormal psychomotor activity, and sleep

cycle impairment
 Often underrecognized by health care

workers
Delirium

 Acute reversible mental disorder characterized

by confusion and some impairment of
consciousness
 Generally associated with emotional lability,

hallucinations or illusions, and inappropriate,

impulsive, irrational, or violent behavior
Delirium Tremens
 Acute and sometimes fatal reaction to
withdrawal from alcohol
 Usually occurring 72 to 96 hours after the

cessation of heavy drinking

 Distinctive characteristics are marked

autonomic hyperactivity (tachycardia, fever,

hyperhidrosis, and dilated pupils)
Delirium Tremens

 Usually accompanied by tremulousness,

hallucinations, illusions, and delusions
 Called alcohol withdrawal with perceptual

disturbance in DSM-5. See also formication.

Delusion
 False belief, based on incorrect inference
about external reality, that is firmly held despite
objective and obvious
 Contradictory proof or evidence and despite

the fact that other members of the culture do

not share the belief
Delusion of Control

 False belief that a person’s will, thoughts,

or feelings are being controlled by external
forces
Delusion of Grandeur
 Exaggerated conception of one’s importance,
power, or identity
Delusion of Infidelity
 False belief that one’s lover is unfaithful
 Sometimes called pathological jealousy
Delusion of Persecution
 False belief of being harassed or persecuted
 Often found in litigious patients who have a

pathological tendency to take legal action

because of imagined mistreatment
 Most common delusion
Delusion of Poverty
 False belief that one is bereft or will be deprived
of all material possessions
Delusion of Reference
 False belief that the behavior of others refers
to oneself or that events, objects, or other
people
 Derived from idea of reference, in which

persons falsely feel that others are talking

about them (e.g. belief that people on
television or radio are talking to or about the
person)
Delusion of Self-accusation
 False feeling of remorse and guilt
 Seen in depression with psychotic features
Hallucination
 False sensory perception occurring in the
absence of any relevant external stimulation
of the sensory modality involved
 For types of hallucinations, see the specific

term
Fundamental Points regarding Drug-
induced Psychosis

 It can be produced by stimulants,

hallucinogens, cannabis, and
sedative/hypnotics (in withdrawal).
 Evidence for lasting psychosis, as opposed to

chronic hallucinosis, caused by drugs is weak.

 Drug use may be incidental in an individual

developing functional psychosis.

Fundamental Points regarding Drug-
induced Psychosis

 Symptoms should subside if drug use is

eliminated.
 Antipsychotic drug treatment resembles that in

functional psychosis but can be ineffective if

drug use continues.
Fundamental Points regarding Drug-
induced Psychosis

 The American Psychiatric Association

coordinated efforts with the WHO in the
preparation of ICD-10, the ‘Mental and
Behavioral Disorders’, to provide an
international classification system that is as
compatible with DSM-IV.
Fundamental Points regarding Drug-
induced Psychosis
 In ICD-10, psychotic disorders can be attributed
to psychoactive substance use under three
conditions:
(1) the onset of symptoms must occur during or
within 2 weeks of substance use
(2) the psychotic symptoms must persist for
more than 48 hours
(3) the duration of the disorder must not
exceed 6 months
Why It Is Important To Know About
Comorbid?

1. It is common.
2. It is frequently misdiagnosed.
3. There is reluctance to seek treatment.
4. There is low treatment completion
(retention rates).
5. There is lower incidence of positive
treatment outcomes (high relapse rates).
 Individuals who are actively using drugs or
alcohol may appear to have mental illnesses
such as: anxiety, depression, psychotic
disorders or personality disorders.
 These mental disorders may disappear over

time (clinically called the “resolution period)

once the body has had time to repair itself from
the toxic effects of drugs and/or alcohol.
 Typically 30 days is enough time to determine
whether the persistence of
symptoms/impairment is sufficient for a
psychiatric diagnosis.
 However, heavy use of certain drugs can extend

the resolution period to 90 days.

Personality Disorders
 Personality : the totality of emotional and
behavioural traits that characterize the person
in day to day living under ordinary conditions
 Personality Disorder

• A variant of those character traits that goes

beyond the range found in most people
• Personality traits are inflexible and
maladaptive and cause either significant
functional impairment or subjective distress
• Ego-syntonic (acceptable to self)
 Antisocial PD – undoubtedly very frequent
precursor of drug misuse (>50%) (Verheul et al.
1995)
– often following from conduct disturbances
in adolescence.
– strong features of antisocial PD are
aggressiveness, irresponsible behaviors
and impulsivity
– Borderline PD- also very frequent
(Seivewright and Daly 1997;Trull et al.2000)
DEPRESSION

 Major depressive disorders

 Psychotic depression
 Dysthyma
 Depressive episode of Bipolar disorder
Summary

 Psychoactive, mood-altering drugs cause

alterations in mood, behavior, thinking, perception,
& memory.
 The relationships between drug use and psychiatric

symptoms include the following:

1. drugs can cause psychiatric symptoms
2. drugs can initiate or worsen existing
psychiatric symptoms and disorders
Summary

3. drugs can mask psychiatric symptoms

4. withdrawal can cause psychiatric
symptoms
5. psychiatric disorders can cause
behavior that resembles the behavior
associated with addiction
Summary

 Sequential Treatment involves first treating one

disorder and then treating the other disorder.
 Parallel Treatment describes simultaneous

treatment of the addiction and the psychiatric

disorder, but through different treatment
programs or providers.
Summary

 The goal of Addiction Treatment is to learn to

live a healthy and productive life without
psychoactive drugs.
 The goal of Psychiatric Treatment includes

eliminating or reducing psychiatric symptoms.

A friendly reminder that ...

 Patients who are presenting for substance

abuse treatment should be screened for
mental disorders.
 All individuals presenting for treatment of

mental disorders should be screened for

substance use disorder.
Learning Objectives:
At the end of the module, the participant should be
able to:
1. identify the most common comorbid or co-
occurring mental disorders.
2. manage patients with dual diagnosis
3. familiarize themselves and identify the different
types of personality disorders among substance
abusers.
4. identify the goals of treatment in addiction and
psychiatry.