Psychiatric Aspects of Adolescent Co-occurring Disorders

Seth Eisenberg MD Medical Director, DHS-DASA October 24, 2011 1

Eisenberg Outline

 Similarities and relationships between AOD and psych symptoms  Mental Status Exam, Diagnosis and Psychiatric Symptoms  Anxiety Disorders  Elements of Medication Treatment  Adolescent Gambling  Ask the Doc 2

AOD Use and Psychiatric Symptoms

AOD use can cause psychiatric symptoms and mimic psychiatric syndromes.

AOD use can initiate or exacerbate a psychiatric disorder.

AOD use can mask psychiatric symptoms and syndromes.

AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes.

Psychiatric and substance use disorders can independently coexist.

Psychiatric behaviors can mimic substance use problems.

SAMHSA TIP #9

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Drugs That Precipitate or Mimic Mood Disorders

Mood Disorders

Depression and dysthymia Mania and cylothymia

During Use (Intoxication)

Alcohol, benzodiazepines, opioids, barbiturates, cannabis, steroids (chronic), stimulants (chronic) Stimulants, alcohol, hallucinogens, inhalants (organic solvents), steroids (chronic, acute)

After Use (Withdrawal)

Alcohol, benzodiazepines, barbiturates, opiates, steroids (chronic), stimulants (chronic) Alcohol, benzodiazepines, barbiturates, opiates, steroids (chronic),

SAMHSA TIP #9

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Adolescent Dependency

GENERAL EFFECTS

The adolescent demonstrating these behaviors may be indicating a problem with drugs and/or alcohol:     Sudden, noticeable personality changes Severe mood swings Changing peer groups Dropping out of extra-curricular activities ADOL-CD Cont’d 5

GENERAL EFFECTS

 Decreased interest in leisure time activities  Worsening grades  Irresponsible attitude toward household jobs and curfews  Depressed feelings much of the time  Dramatic change in personal hygiene concern  Changes in sleeping or eating habits ADOL-CD Cont’d 6

GENERAL EFFECTS

 Smell of alcohol or pot  Sudden weight loss  Tendency toward increasing dishonesty  Trouble with the law  Truancy from school ADOL-CD Cont’d 7

GENERAL EFFECTS

 Frequent job losses or changes  Turned off attitude if drugs are discussed  Missing household money or objects  Increasing time alone in his/her room ADOL-CD Cont’d 8

GENERAL EFFECTS

 Deteriorating family relationships  Drug use paraphernalia, booze, or empty bottles found hidden  Observations of negative behavior by people within or outside immediate family  Obvious signs of physical intoxication ADOL-CD Cont’d 9

GENERAL EFFECTS

Some of these behaviors are a sign of typical adolescent development, BUT, a wide variety of them in one person should raise suspicions of the likelihood of harmful involvement with drugs or alcohol….

OR—some kind of psychiatric problem ADOL-CD Cont’d 10

Adolescent Comorbidity

The syndrome most consistently associated with substance use is

delinquent behavior

, followed by scales measuring social problems and attention problems 11

Adolescent Comorbidity

The likelihood of substance use among adolescents is associated with the severity of emotional and behavioral problems across age and gender groups.

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Adolescent Comorbidity

Past-month marijuana use was nearly 2x as likely and use of other drugs was 4x more likely for adolescents with serious emotional problems than for adolescents with low levels of emotional problems.

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Adolescent Comorbidity

Past-month marijuana use was 4x as likely, and use of other drugs was nearly 7x more likely, for adolescents with serious behavioral problems than for adolescents with low levels of behavioral problems. 14

Adolescent Comorbidity

Dependence on substances such as cocaine, crack, inhalants, hallucinogens, heroin or prescription drugs was nearly 9x as likely among adolescents with serious behavioral

problems.

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Adolescent Comorbidity

Past-month alcohol use was nearly 2x as likely for

adolescents with serious emotional problems

than for adolescents with low levels of emotional problems.

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Adolescent Comorbidity

Adolescents with serious behavioral problems were nearly 3x as likely to use alcohol in the past month than adolescents with low levels of behavioral problems 17

Adolescent Comorbidity

Adolescents with serious emotional problems were nearly 4x more likely to be dependent on alcohol or illicit drugs than adolescents with low levels of emotional problems.

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Adolescent Comorbidity

Alcohol or drug dependence was more likely among adolescents with serious behavioral problems than among adolescents with low levels of behavioral problems 19

Adolescent Comorbidity

Stealing, swearing, hanging around with troublemakers and running away from home -

Feeling confused or in a fog

were associated with more substance use 20

Adolescent Comorbidity

While overall substance use is generally higher for adolescent males than for females, females with high ratings for psychosocial problems as measured by the YSR were as likely as males to smoke cigarettes, binge drink or use illicit drugs.

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Adolescent Comorbidity

Risk Factors

• Juvenile Delinquency • Runaways • High School Dropouts • Youth With Psychiatric Disorders • Unmarried Pregnant Adolescents • Youth That Have Been Physically, Sexually, or Emotionally Abused 22

Adolescent Comorbidity

Risk Factors

• Unsatisfactory Family Relations • Children in Foster Care • Extreme Sexual Activity • Exploited Youth • School Difficulty - Low G.P.A.

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Adolescent Comorbidity

Risk Factors

• Family Social Deprivation, i.e., Poverty • Association with Delinquent Peers • Neighborhood/Community Disorganization • Affiliation with Peers of Other Dysfunctional Family Systems 24

Adolescent Comorbidity

Characteristic Profile

• More Impulsive • Less Mature • More Peer Oriented • Restless (tension reduction oriented) 25

Adolescent Comorbidity

Characteristic Profile

• Rebellious • Increased Sadness • Increased Social Withdrawal • Learning Problems 26

Adolescent Chemical Dependency

Individual Risk

 Low self esteem  Feelings of not belonging  Poor coping skills  Poor interpersonal skills  Poor situational skills, poor judgement  Biogenetic factors ADOL-CD Cont’d 27

Adolescent Comorbidity

When Compared to Non-CD Psychiatric Cases • Earlier First Use of Drugs (14 vs 12) • Increased Divorce (56% vs 26%) • Increased Parental CD • Increased Parental Psychiatric Illness 28

Adolescent Comorbidity

When Compared to Non-CD Psychiatric Cases • More Legal Problems • Increased Special Education Placement • More Frequent Suicide Attempts • Increased Residential Placement 29

Adolescent Comorbidity

Associated with: • Earlier Onset of Abuse Behaviors • Greater Clinical Severity • Poorer Outcomes • Increased Disturbance of Relationships 30

Adolescent Comorbidity

Associated with: • Differential Responsiveness to CD Treatment • Increased Risk of Relapse • Less than Optimal Functioning when Abstinent 31

Adolescent Comorbidity

Diagnostic Considerations • Impact of Chemical Use -decreased withdrawal symptoms -varied expression of use -negative effect on development • Emerging Psychiatric Illness -usual age of onset -precipitating event 32

Adolescent Comorbidity

Diagnostic Considerations • Commonality of Symptoms of Psychiatric Disorders - ADHD, bipolar, depression, CD, anxiety • Confounding Symptoms of Adolescent CD - Intoxication - Chronic use - ABCD-S 33

Adolescent Comorbidity

Adolescent Behavior CD Syndrome • High Delinquency • Hyperactivity • Decreased School Performance • Decreased Social Competence/Participation • Depressed Behaviors • Onset after development of CD and subsides 2 months after onset of sobriety 34

Adolescent Comorbidity

ABCD-S (Continued) • May Result In: -developmental dysfunction -hyperactivity, distractibility -restlessness, impulsivity -depression and suicide • Possible Overdiagnosis of Psychiatric illness 35

Diagnostic Dilemmas

 Psychoactive substances have profound effects on neurotransmitter systems – Neurotransmitters may be involved in psychiatric disease states – May unmask genetic vulnerability – May cause a psychiatric disease  It may be difficult to differentiate which diagnosis is primary, ie which “came first” 36

Psychiatric Diagnosis

Mental Status Exam and Psychiatric Symptoms 37

MENTAL STATUS EXAMINATION (MSE) APPEARANCE SPEECH EMOTIONS (mood & affect) THOUGHT PROCESS THOUGHT CONTENT PERCEPTIONS Formal or MINI MSE ORIENTATION MEMORY CONCENTRATION INSIGHT JUDGMENT IMPULSE CONTROL

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MENTAL STATUS EXAMINATION (MSE)

Appearance – Physical appearance, mannerisms, attitude Speech – Rate, rhythm, volume, articulation Mood – “how do you feel today” Affect – Outward expression of inner mood: range, intensity, stability, appropriate 39

MENTAL STATUS EXAMINATION (MSE)

Thought Process – Productivity, continuity, coherence Thought Content – fears, obsessions, paranoia, suicide, violence Perceptions – Hallucinations and illusions, depersonalization Orientation and Cognition (formal MSE) 40

Overview of Psychiatric Disorders and Symptoms  Schizophrenia and Psychosis  Mood Disorders  Anxiety Disorders  ADHD and Impulse Control Disorders  Personality Disorders  Developmental Disorders  Sleep Problems 41

Schizophrenia and Other Psychotic Disorders

 Schizophrenia  Schizophreniform  Schizoaffective Disorder  Delusional Disorder  Brief Psychotic Disorder  Substance Induced Psychotic Disorder 42

Symptoms of Psychosis

 Hallucinations  Delusions (bizarre and non-bizarre)  Disorganized speech  Disorganized thinking  Disorganized behavior or catatonia  “negative symptoms” 43

Antipsychotics/Neuroleptics Traditional—First Generation  chlorpromazine  fluphenazine  haloperidol  perphenaxzine  thioridazine  thiothixene  trifluoperazine Thorazine, Prolixin, Haldol (decanoate), Trilafon, Mellaril, Navane, Stelazine 44

Antipsychotics/Neuroleptics Atypical, Novel—Second Generation  aripiprazole  clozapine  olanzapine  quetiapine  risperidone  ziprasidone Abilify, Clozaril, Zyprexa (zydis), Seroquel, Risperdal Geodon, Saphris, Fanapt, Latuda • Consta • • Invega Sustena Relprev 45

Mood Disorders

 Depressive Disorders – Major Depressive Disorder – Dysthymic Disorder  BiPolar Disorders – Bipolar I – Bipolar II  Cyclothymic Disorder  Substance Induced Mood Disorder 46

Symptoms of Depression

 Depressed mood, sadness, crying  Decreased interest and pleasure  Decreased energy and activity  Weight change, sleep change  Low self esteem, worthlessness, guilt  Decreased concentration 

Suicidal ideation

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ADOLESCENT COMORBIDITY

Depression •Mostly studied - high prevalence in adults •Approximately 80% clear in two weeks •In adolescents - frequent suicidality •Suicide attempts with increased medical seriousness and lethality •Family history important •Developmental history important 48

 citalopram  escitalopram  fluoxetine  fluvoxamine  paroxetine  setraline A ntidepressants SSRIs Celexa, Lexapro, Prozac, Prozac weekly, Sarafem Luvox, Paxil, Paxil CR, Zoloft Cymbalta, Pristiq, Paxeva 49

 amitriptyline  clomipramine  desipramine  doxipin  imipramine  maprotiline  nortriptyline  protriptyline A ntidepressants Tricyclics Elavil, Anafranil, Norpramin, Sinequan, Tofranil, Ludiomil, Pamelor, Vivactil 50

 buproprion  mirtazapine  trazadone  venlafaxline  isocarboxazide  phenelzine  tranylcypromine A ntidepressants Others Wellbutrin (SR, XL), Remeron, Deseryl, Effexor (ER), Marplan, Nardil, Parnate 51

Symptoms of Bipolar Mania

 Elevated, expansive mood of well being  More irritable or agitated  Grandiose delusions  Decreased need for sleep  More talkative than usual  Racing thoughts  More action and activity  Increased distractibility 52

Antimanic Medications  lithium  carbamazepine  divalproex sodium  gabapentin  lamotrigine  oxcarbazepine  Topiramate Atypical Antipsychotics Eskalith, Tegratol, Depakote, Neurontin, Lamictal, Trileptal, Topamax 53

Anxiety Disorders

What is Anxiety?

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Symptoms of Anxiety autonomic hyperactivity increased hand tremor insomnia nausea or vomiting psychomotor agitation Anxiety

Nervous, tense, fearful and high strung

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Symptoms of Anxiety

 Panic attacks and fear of panic attacks  Excessive worry about everything  Intrusive memories, flashbacks, fears  Excessive anxiety in social situations—fear of negative judgment and embarrassment  Repeating thoughts or behaviors 56

Anxiety Disorders

 Panic Disorder--with agoraphobia  Social Phobia  Generalized Anxiety Disorder  Obsessive-Compulsive Disorder  Acute Stress Disorder  Posttraumatic Stress Disorder  Substance-Induced Anxiety Disorder 57

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Panic Attack

Palpitations, pounding, chest pain/discomfort  Sweating  Trembling or shaking  SOB  Feeling of choking  Nausea or abdominal distress  Dizzy, unsteady, lightheaded or faint  Derealization, depersonalization  Fear of losing control, going crazy, dying 58

Agoraphobia

 Anxiety about being in places or situations from which escape might be difficult (or embarrassing) in the event of a panic attack  The situations are avoided or are endured with marked distress  Anxiety or phobic avoidance is not better accounted for by another mental disorder 59

Social Phobia

 Marked and persistent fear of social or performance situations, possible scrutiny by others or may act in a way that will be embarrassing or humiliating  Exposure to feared social situation provokes anxiety (or may have panic attack)  Person recognizes that the fear is excessive  Feared situations are avoided or endured  Avoidance, anxious anticipation or distress interferes with functioning 60

Social Phobia

“Marked and persistent fear of social or performance situations in which embarrassment may occur” (DSM IV)  Prevalence 12% to 56% in alcoholic populations  May interfere with treatment  Specific symptoms for diagnosis  SSRIs (delayed effect) 61

Generalized Anxiety Disorder

   Excessive anxiety and worry (apprehensive expectation) about number of events occurring more days than not Difficult to control the worry Associated with three or more frequently present – Restlessness or feeling keyed up, on edge – Easily fatigued, – Irritability – difficulty concentrating or mind going blank – Muscle tension – Sleep disturbance 62

Obsessive-Compulsive Disorder

Obsessions  Recurrent persistent thoughts, impulses or images—intrusive and inappropriate and cause anxiety or distress  Not simply excessive worries  Person attempts to ignore or suppress or neutralize  Recognized as a product of own mind 63

Obsessive-Compulsive Disorder

Compulsions  Repetitive behaviors or mental acts the person feels driven to perform in response to obsession or according to certain rules  The behaviors or mental acts are aimed a preventing or reducing distress or preventing some dreaded act (not realistic)  At some point are recognized as excessilve or unreasonable  Cause marked distress or are time consuming or significantly interfere 64

Acute Stress Disorder

 Exposed to traumatic event with serious threat and feelings of intense fear, helplessness or horror  During or after event had three or more: – Numbing, detachment or lack of emotions – Reduction in awareness of surroundings – Derealization – Depersonalization – Dissociative amnesia 65

Acute Stress Disorder

 Traumatic event is re experienced with images, thoughts, dreams, flashbacks, reliving or distress with reminders  Marked avoidance of stimuli that remind  Marked symptoms of anxiety or increased arousal (poor sleep, irritable, startle, etc)  Causes significant distress or impairment  Lasts a minimum of 2 days and maximum of 4 weeks and occurs w/in 4 weeks 66

Post-Traumatic Stress Disorder

“Development of symptoms following exposure to an extreme traumatic stressor” (DSM IV)  30% to 50% prevalence in SUD treatment seekers  Goal to reduce key symptoms  Target symptom constellations  TCAs and MAOI’s - Depressive and     intrusive Neuroleptics - Psychosis and dissociation Carbamazipine - Impulse dyscontrol Clonidine, Beta Blockers, Benzos SSRIs arousal 67

ADOLESCENT COMORBIDITY PTSD •Child/adolescent sexual and physical abuse •Increased depression, anxiety, negative self concept, suicidal behavior •Adolescent antisocial behavior 68

ADOLESCENT COMORBIDITY PTSD •Increased school problems, run away, placement, legal difficulties •More drugs with more frequent use •Motivation for substance use -reduce tension -sleep -relieve pain or discomfort -escape family problems 69

Antianxiety Medications  alprazolam  chlordiazepoxide  clonazepam  diazepam  lorazepam  oxazepam  buspirone  propranolol  hydroxyzine Xanex, Librium, Klonopin, Valium, Ativan, Serax, Buspar, Inderal, Atarax (Vistaril)

SSRIs

Atypicals 70

Anxiety Disorders and SUD Medication Treatment

Panic Disorder (5-42% in AUD, 7-13% in MMT)  SSRI, TCA, MAOI, benzodiazepines all effective (not studied in COD populations)  May have initial activation with SSRI and TCA that could increase risk of relapse—use low dose initiation  Latency of onset of effect, 2-6 weeks  SSRIs—no abuse potential, safe, generally well tolerated, may help with ETOH 71

Anxiety Disorders and SUD Medication Treatment

 Benzos usually avoided in SUD populations (but not an absolute contraindication)  Panic disorder can also be treated with anticonvulsants (valproate or carbamazepine) and Panic with stimulant abuse may respond to these agents due to neuronal sensitization and limbic excitability  TCAs carry risk of lower seizure threshold and interactions with ETOH, depressants and stimulants 72

Anxiety Disorders and SUD Medication Treatment

Social Anxiety Disorder (8-56% in AUD, 14% in cocaine, 6% in MMT)  In most cases SAD precedes AUD so a period of abstinence not so important  Early identification important with COD as SAD may interfere with SUD treatment  SSRI have FDA indication (paroxetine) and may also reduce alcohol use  Venlafaxine and gabapentin 73

Anxiety Disorders and SUD Medication Treatment

Generalized Anxiety Disorder (8-52% in AUD, 21% in MMT, 8% in cocaine)  Diagnostic difficulties—overlap with symptoms of acute intoxication with stimulants and withdrawal from alcohol and sedatives (and anxiety in early recovery--PAWS)  SSRI, TCA, venlafaxine, anticonvulsants  Use of benzodiazepines is controversial  Buspirone may be effective 74

Comorbid Anxiety and Alcohol Which Comes First?  Risk of getting new ETOH Dep as a Jr/Sr more than tripled among students with anxiety dx as a freshman.  Students with ETOH Dep as freshman were 4xmore likely to dev. an anxiety d/o (6yrs)  So having either an anxiety or ETOH d/o earlier in life apears to increase the probability of developing the other later 75

Comorbid Anxiety and Alcohol Comorbidity Models 1.

2.

3.

– Having an anxiety disorder predisposes one to develop an SUD via self medication “anxiety induced” substance use disorder – The social, occupational and physiologic effects of substance use can generate new anxiety symptoms in vulnerables Not the same as “substance induced” Third factor can serve as a common cause for both conditions ( underlying genetic or physiologic liability) 76

ADHD

 Hyperactivity and inattention – Impulsive, overactive, impatient, intrusive – Distracted, poor concentration, procrastinates, disorganized and forgetful 77

ADOLESCENT COMORBIDITY

Attention Deficit/Hyperactivity Disorder •Differential Diagnosis -bipolar -LD -Mood and anxiety -ABCD-S •Psychiatric Cormorbidity •Multiple Risks for Substance Abuse •In Adults 78

ADOLESCENT COMORBIDITY

AD/HD - Treatment Considerations •Require Special Programming •Chronic Experience of Failure •Mood Problems - Self Esteem •Disruptive Behaviors •Learning Problems •Difficult family Situations 79

Stimulant Medications and Non-Stimulants          D-amphetamine L & d-amphetamine Methamphetamine Methylphenidate Pemoline Modafinil Atomoxetine Bupropropion Guanefacine-clonidine Dexedrine, Adderall, Desoxyn, Ritalin, Concerta, Metadate, Focalin, Cylert, Provigil, Strattera, Wellbutrin, Tenex Intuniv 80

Personality Disorders

 Antisocial Personality Disorder  Paranoid Personality Disorder  Schizoid and Schizotypal PD  Borderline Personality Disorder  Narcissistic Personality Disorder  Avoidant Personality Disorder  Dependent Personality Disorder 81

Developmental and Organic Disorders

 Mental Retardation and other syndromes  Autism and Asperger’s  Learning Disabilities  Communication Disorders  Tic Disorders Cognitive impairment from seizures, traumatic brain injury, medical, drugs and alcohol 82

Medication Treatment of Psychiatric and Substance Use Disorders

Psychotherapeutic Medications: What Every Counselor Should Know Mid-America Addictions Technology Transfer Center

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Medication Treatment General Principles Pharmacologic effects:  Therapeutic—indicated purpose and desired outcome  Detrimental—unwanted side effects (may interfere with adherence), potential for abuse and addiction Need a balance between therapeutic and detrimental 84

Medication Treatment General Principles Psychoactive Potential: Ability of some medications to cause distinct change in mood or thought and psychomotor effects – Stimulation, sedation, euphoria – Delusions, hallucinations, illusions – Motor acceleration or retardation All drugs of abuse are psychoactive 85

Medication Treatment General Principles  Many medications are non-psychoactive (except for mild side effects including sedation or stimulation)  Not considered euphorigenic( although can be misused and abused)  Psychoactive drugs considered high risk for abuse and addiction  Some psychoactive meds have less addiction potential (old antihistimines) 86

Medication Treatment General Principles Positive reinforcement—increase the likelihood of repeated use – Amplification of positive symptoms or states – Removal of negative symptoms or conditions – Faster reinforcement, more prone to misuse Tolerance and Withdrawal – Higher risk for abuse and addiction More concerns when prescribing to high-risk patients 87

Medication Treatment Stepwise Treatment Model  Risks/benefits analysis (risk of medication, risk of untreated condition, interactions, potential for therapeutic benefits)  Early and aggressive treatment of severe psychiatric problems  Start with more conservative approach with high risk patients and less severe conditions 88

Medication Treatment Stepwise Treatment Model High risk patients with anxiety disorder 1. Non-pharmacologic approaches when possible 2. Non-psychoactive medications added next as adjunctive treatment 3. Psychoactive medications when other treatments fail 89

Medication Treatment Stepwise Treatment Model  Non-pharmacologic approaches – Psychotherapy, cognitive and behavioral tx, stress management skills, medication, exercise biofeedback, acupuncture, education, etc  Use meds with low abuse potential  Conservative approach not the same as under medicating  Different treatments should be complementary, not competitive 90

Talking to Patients about Medications  Make an inquiry every few sessions  Are their Psych meds. Helpful? How?

 How many doses or how often do you miss?

 Acknowledge that taking pills everyday is a hassle and everybody misses sometimes  Did they feel or act different? Or use?

 Explore connections of MH, meds, use  Forget? Or choose not to take it.

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Medication Adherence Comorbid SUD: a Risk for Non-adherence  May have conflicted feelings and attitudes about medication  Meds may be sometimes discouraged or thought to be un-needed  See it as a sign of weakness  May stop meds during relapse  May misused meds 92

Talking to Patients about Medications  Problem solve strategies to not forget – Use a pill box, help set it up – Keep it where it cannot be missed or avoided – Link med taking with some daily activity – Use an alarm clock set for the time to take – Ask someone to help them take meds 93

Talking to Patients about Medications  Some patients may choose not to take meds – They have a right to make that choice – Owe it to themselves to make sure their important health decision is well thought out – Explore-- “I just don’t like pills (or meds)”. – Elicit a reason—never needed it, cured now, don’t believe in it, means I’m crazy, side effects, afraid, shame, cost, interpersonal, want to be in control, do it on my own, can’t use – Motivational Interviewing 94

Using an Empathic Style

An Empathic Style  Communicates respect for and acceptance of clients and their feelings  Encourages a nonjudgmental, collaborative relationship  Allows the clinician to be a supportive and knowledgeable consultant 95

Using an Empathic Style

An Empathic Style  Compliments and reinforces the client whenever possible  Listens rather than tells  Gently persuades, with the understanding that the decision to change is the client’s  Provides support throughout the recovery process 96

Motives for Adolescent Gambling Behavior

 Relaxation  Enjoyment, Excitement, Entertainment  Adventure, Attention  Opportunity  Negative feelings 97

Why Do Youth Gamble?

 Excitement  Entertainment  Escape  Economics  Ego 98

Psychiatric Comorbidity

Effects of Family Gambling     May be effected directly or indirectly Impact on kids depends on how disorganized or dysfunctional the family is to begin with and how much gambling disrupts family routines Impact is greater if parents are pulled away from their roles as caretakers Impact on children also related to: – .Age of children – .Underlying personalities and character – .Amount of marital discord 99

Psychiatric Comorbidity

Effects of Family Gambling     Children may feel responsible for things they don’t understand and become anxious and guilt ridden—they may develop certain roles they play in the family Children may get pulled into deceit and subterfuge by the gambler parent Experience may ultimately shape the child’s values about money Children may manifest a wide variety of behaviors and moods at home, at school or in the community 100

Psychiatric Comorbidity

 Most consistent finding is depression  Themes of guilt, self-punishment  Hopelessness, lack of motivation, suicide and loneliness  Self-destructive excessive risk-taking  Significant life events before depression  2/3 of life events after gambling  Subsets of gamblers 101

Psychiatric Comorbidity

DSM-IV  Depression-with high suicidality  Bipolar Disorder and Cyclothymia  ADHD  Personality Disorders (APD, NPD, BPD)  General medical conditions with stress  Substance use disorders  Urge to gamble increases during periods of stress or depression 102

Psychiatric Comorbidity

Psychiatric Typology-Blaszczynski  “Normal” problem gamblers  Emotionally disturbed gamblers  Biological correlates of gambling 103

Pathological Gambling and Substance Abuse

 More severe substance abuse history  More episodes of overdose  More prior AOD treatment  Used a greater variety of drugs  Greater past use of ETOH, opiates and solvents  Greater history of legal problems 104

Why Harm Reduction for Adolescent Gambling

 Gambling is a SOCIALLY ACCEPTABLE ACTIVITY  Entertainment  Unique: no social barriers  Promoted in the home environment 105

Adolescent Chemical Dependency Treatment and Outcomes

•Multidimensional and multidisciplinary •Developmental status - habilitation vs. rehabilitation •Flexibility - stages of change •Family therapy - family issues •Treatment programs - long term OP vs. short term inpatient 106

Adolescent Chemical Dependency Treatment and Outcomes

•Treatment completion, parental involve- ment and aftercare •Good social supports, self esteem and coping skills •Greatest relapse risk during first 3 months (>60%) •Relapse associated with delinquency, social and peer influence, drug craving, less productive and recreational activities 107

Ask the Doc

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