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RAWATAN KLIEN DUA DIAGNOSIS
(PSIKIATRIK SEMASA DETOKSIFIKASI)
DR OMAR ALIPakar Perunding Psikiatri
Hospital Sultanah Bahiyah
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What is Dual Diagnosis?
Dual diagnosis exists where
alcohol or drug problem and
an emotional/another mental
health(psychiatric) problem
Also known as Co-morbidity
Co-occuring disorders
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Substance Abuse and Mental
Illness
A dual diagnosis orco-occurring disorder occurs when an
individual is affected by both chemical dependency and mental
illness.
Both illnesses may affect a person physically, socially,
psychologically, and spiritually. Each illness has symptoms thatinterfere with a persons ability to function effectively.
The illnesses may affect each other, and each disorder
predisposes to relapse in the other disease. At times the
symptoms can overlap and even mask as each other, makingtreatment and diagnosis difficult.
To fully recover, a person needs to treat/address both disorders.
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How Common Is Dual Diagnosis?
37% of people abusing alcohol53% people abusing other drugs
Have at least one serious mental illness.
29% of people diagnosed as mentally ill,
abuse either alcohol or drugs.American Medical Association
74% of users of drug services
85% of users of alcohol services
experienced mental health problems.
44% of mental health service users reported drug use.
UK Dept. of Health
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Sains Malaysiana 42(3)(2013): 417421
Psychiatric Comorbidity Among Community-based, Treatment
Seeking Opioid Dependents in Klang Valley
(Komorbiditi Penyakit Psikiatri dalam Kalangan Penagih yang
Bergantung pada Opioid di Lembah Kelang)
AzLin BAhAruDin*, LOTfi AnuAr, SuriATi SAini, OSMAn Che BAKAr,
rOSDinOM rAzALi & niK ruzyAnei niK JAAfAr
204 penagih
43.6% daripada kumpulan penagih opioid inimempunyai komorbiditi psikiatri. Penyakit Kemurungan 32.6%,
penyakit disthiamia pada 23.6%
penyakit Panik pada 14.6%.
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Sains Malaysiana 42(3)(2013): 417421
Psychiatric Comorbidity Among Community-based, Treatment
Seeking Opioid Dependents in Klang Valley
(Komorbiditi Penyakit Psikiatri dalam Kalangan Penagih yang
Bergantung pada Opioid di Lembah Kelang)
AzLin BAhAruDin*, LOTfi AnuAr, SuriATi SAini, OSMAn Che BAKAr,
rOSDinOM rAzALi & niK ruzyAnei niK JAAfAr
Komorbiditi psikiatri didapati mempunyai perbezaan siknifikan (p
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So what?
Must be dry to access most addiction rehab
services
Cant get dry because of mental health issue
e.g. anxiety-self medicate e.g. drink to reduce
anxiety
Addiction Treatment centres dont assess for
other mental health problems
Reduces chances of long term recovery
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Contoh Client / Pesakit
DIN
Zahari
Nizam
See Leng
Zul
Mr x
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Why is dual diagnosis a problem?
Historically addiction seen as Moral issue
Form of mania
Disease
Addiction and mental health services separate AA/rehab centres: bias against medication
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Dual Diagnosis Problems
76% of services failing to offer a specificservice for people with dual diagnosis
Dual Diagnosis not clearly understood or
formally recognised Service models used aligned to organisations
rather than complex needs of people with
dual diagnosisMental health & addiction services and the management of dual
diagnosis in Ireland National Advisory Committee on Drugs 2004.
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Diagnosis #1:
MENTAL ILLNESS
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What is Mental Illness:
Mental Illness Facts
Mental illnesses are medical conditions that
disrupt a persons thinking, feeling, mood, ability
to relate to others, and daily functioning. Just as
diabetes is a disorder of the pancreas, mental
illnesses are medical conditions that often result
in a diminished capacity for coping with the
ordinary demands of life.
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Serious mental illnesses
Include:
major depression
schizophrenia
bipolar disorder
obsessive compulsive disorder (OCD)
panic disorder
post traumatic stress disorder (PTSD)
borderline personality disorder
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In Addition to Medication Treatment
Psychosocial treatment such as cognitive behavioral therapy,
interpersonal therapy,
peer support groups,
and other community services can also be components ofa treatment plan that assist with recovery.
The availability of transportation, diet, exercise, sleep,friends, and meaningful paid or volunteer activitiescontribute to overall health and wellness, includingmental illness recovery.
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Diagnosis Specific Signs and
Symptoms
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Major Depression
Dysphoric mood
At least 4 of the following
Changes in appetite and sleep patterns, agitation, loss
of interest in pleasurable activities, fatigue,worthlessness, guilt, inability to concentrate,
ruminating negative thoughts, feeling helpless and
hopeless, recurrent thoughts of death
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Signs and Symptoms of Depression
Tearful
Changes in sleeping patterns
suicidal ideation
changes in appetite loss of pleasure
isolation
sudden outburst of anger
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Difficulty concentrating
Ruminating thoughts
Feeling helpless
Feeling hopeless
Feeling like life is not worth living
Ruminating on negative thoughts
Emotional numbness
Signs and Symptoms of Depression
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Bipolar Disorder
Bipolar disorder, also known as manic depression, is a brain
disorder that causes unusual shifts in a person's mood, energy, and
ability to function. Different from the normal ups and downs that
everyone goes through, the symptoms of bipolar disorder aresevere. They can result in damaged relationships, poor job or school
performance and even suicide.
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Bipolar Disorder: Manic
One of more distinct period with a predominantly elevate,
expansive or irritable mood
Duration of at least one week during which most of the time at
least 3 have been present
Increase in activity, hyper verbal or pressured speech, flights ofideas, grandiosity, decreased need for help, distractibility,
buying sprees, sexual indiscretions, foolish business
investments, reckless driving
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Personality Disorders
Each of us has a personality or group of characteristics(traits) which influence the way we think, feel & behave and
makes us a unique individual.
Someone may be described as having a 'personality disorder'
if their personal characteristics cause regular and long termproblems in the way they cope with life and interact with
other people. Some people with these disorders never come
into contact with the mental health services.
APA: when personality traits are inflexible and maladaptive
and cause either significant impairment in social oroccupational functioning or subjective distress.
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Personality Disorders
Approximately 10-13% of the population have
a personality disorder. Personality disorders
are more common in younger age groups(25-44 year age group) and are equally
distributed between males and females.
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Personality Disorders
Prominent characteristics
Tx of problematic relationships
Blames difficulties on others or bad fortune
Doesnt learn from mistakes Generate and perpetuate existing problems
Lack of control over emotions
Distorted thinking
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Types of Personality Disorders
Divided into 3 Clusters:
A) odd/eccentric : paranoid, schizoid
B) dramatic/erratic: antisocial, borderline,histrionic, narcissistic
C) anxious/inhibited: dependent, avoidant,
obsessive-compulsive
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Antisocial Personality Disorder
Current age of at least 18
Onset before 15 as indicated by 3 or more:
Truancy, expulsion, delinquency, running away
from home, arrested, persistent lying, repeated
sexual intercourse, repeated drunkenness or
substance abuse, thefts, vandalism, low school
grades, chronic violations of home rules, initiationof fights
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Antisocial Personality Disorder
At least 4 of the following since age 18:
Inability to sustain consistent work behavior
Lack of ability to function as a responsible parent
Failure to accept social norms with respect to lawful
behavior
Inability to maintain enduring attachment to a sexual
partner
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Antisocial Personality Disorder
Irritability and aggressiveness
Failure to honor financial obligations
Failure to plan ahead or impulsivity
Disregard for the truth
Recklessness
A pattern of continuous antisocial behavior in which
the rights of others are violated
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Borderline Personality Disorder
At least 5 of the following:
Impulsivity or unpredictability in at least 2 areas that are
potentially self damaging-Spending, sex, gambling, shoplifting,
AOD use, etc
A pattern of unstable and intense interpersonal relationships
Inappropriate, intense anger or lack of control over anger
Identity disturbances
Affective instability
Intolerance of being alone
Physical self damaging acts
Chronic feelings of emptiness and boredom
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The Good News About Mental Illness:
Is that recovery is possible.
Mental illnesses can affect persons of any age, race, religion, or
income.
Mental illnesses are not the result of personal weakness, lack ofcharacter, or poor upbringing.
Most people diagnosed with a serious mental illness can
experience relief from their symptoms by actively participating
in an individual treatment plan.
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Diagnosis #2:
SUBSTANCE ABUSE
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Addiction = A Dog with a Bone
It never wants to let go.
It bugs you until it gets
what you want.
It never forgets
when/where it is used to
getting its bone.
It thinks its going to get abone anytime I do anything
that reminds it of the bone.
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Substance Abuse and Mental Illness
= Co-Occurring Disorder
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Co-Occurring Risk Factors
Childhood risk factors such as poverty, family discord, and pre
and postnatal complications appear to be implicated in both
mental illness and substance use.
Between 51 and 97 percent of women with serious mental
illness have been physically or sexually abused.
41 to 71 percent of women treated for alcohol or drug use report
being sexually abused.
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Stigmas
Alcohol and drug abuse have many negative
connotations in our society. For many, drug
abuse is perceived to result from lack of
willpower, laziness, or selfishness. Sadly, theseerroneous perceptions also extend to a group
extremely vulnerable to drug abuse people with
mental disorders.
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Relationship between Substance
Abuse and Mental Illness
Those with a mental disorder can be very sensitive tothe effects of drug abuse; not only can it be easier toabuse drugs, it can also be harder to quit.
Like the rest of the population, a person with a mental
disorder is more likely to abuse drugs if there is afamily history of alcohol and drug abuse.
Environmental factors such as peer pressure,location, and the availability of the drug alsocontribute to a pattern of drug abuse in the mentallyill.
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Relationship between Substance
Abuse and Mental Illness, cont.
Drug use can interfere with prescribed medication,
increase symptoms of a mental condition, and
increase relapse risk.
Having difficulty developing social relationships,some people find themselves more easily accepted by
groups whose social activity is based on drug use.
Some believe that an identity based on drug
addiction/alcoholism is more acceptable than one
based on mental illness.
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Theories of Dual-Diagnosis
Self-medication theory: Substances are selectivelyused in service of alleviating symptoms of mentalillness (i.e. stimulant abuse employed to counter thesedative effects of anti-psychotic medications)
Alleviation of dysphoria: mental illness creates
dysphoria (feeling bad) and this dysphoria leads todrug use to mitigate the experience of theseunpleasant feelings
Multiple risk: In addition to the alleviation of bad-feelings, there are additional risks such as: social
isolation, poverty, lack of daily structure, residing inareas with drug availability, history of traumaticevents
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Some Key Factors
Studies in the UK and United States haveindicated that individuals with dual-diagnosishave a number of difficulties and poorer
outcomes including: Increased severity of symptoms and relapse
More frequent inpatient hospital admissions
Higher treatment costs Increased hostility and involvement with the
legal system
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Key Factors Continued
Increase likelihood of suicide
Increased rate of homelessness and insecure
housing
Increased risk of HIV infection
Family problems or intimate relationships
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Ciri-ciri Relapse
Rasmussen (2000) ada menggariskan ciri-ciri relapse ialah perubahan dalaman individu seperi
peningkatan stress,
perubahan pemikiran,perasaan dan tingkah laku;menafikan tentang rasa kebimbangan yang dialami;
menghindari dan mempertahan diri sendiri bahawa tidak relapse sebaliknya memfokuskan kepada oranglain,
bersifat defensive,
bersifat kompulsif,berkelakuan impulsive
krisis lanjutan seperti melihat remeh sesuatu masalah,perasaan yang tertekan, perancangan masa hadapan yang lemah dan gagal;
berfikiran bahawa semua perkara tidak dapat diselesaikan
bertindak secara tidak matang untuk tujuan bergenbira atau berseronok.Individu juga berasa keliru dan memberi reaksi yang berlebihan kesan daripada tidak dapat berfikir dengan
jelas, tidak dapat mengurus perasaan dan emosi ,
sukar untuk mengingati sesuatu,berasa keliru.
tidak dapat mengawal stres dan menjadi mudah marah.
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Ciri-ciri Relapse
kemurungan (depression) tabiat makan yang luar biasa (tidak lalu atau terlalu banyak makan),
kurang bersemangat untuk mengambil sesuatu tindakan,
sukar untuk tidur,
terjejas aktiviti harian
mengalamisuatu tempoh tekanan yang agak lama.
Individu yang relapse juga akan kehilangan kawalan kerana memendam perasaan, berasa tidak mampu dan tidak berguna,
menolak pertolongan,
melanggari program pemulihan,melanggar nilai nilai diri,
hilang keyakinan diri,marah tanpa sebab,suka bersendirian,kecewa
mengalami tekanan.
Ciri-ciri terakhir ialah individu mula relapse dengan mengambil dadah akibatnya berperasaankecewa,hilang kawalan diri dan kehidupan serta kemerosotan tahap kesihatan.
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PENCEGAHAN DADAH MELALUI RAWATAN
Pendekatan farmakologiPendekatan farmakologi bergantung kepada ubat-ubatan atau dadahuntuk menyekat kesan euforik, ataupun mengurangkan kegianan sertaslmptom putus dadah (withdrawl symptoms) semasa dadah digunakan
methadone, -
Naltrexone,
buprenorphine,
ubat-ubatan juga digunakan dalam proses detoksifikasi dengan tujuan untukmengawal kegianan.
dadah digunakan bagi mengurangkan masalah dual-diagnosis sepertikemurungan atau skizofrenia.
prevalen salah guna bahan dalam kalangan kes mental seperti inimencapai 50 peratus.
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The Four Quadrant Model
The Four Quadrant Model is a viable mechanism
for categorizing individuals with co-occurring
disorders for the purpose of service planning
and system responsibility.
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Sub-Groups of Dual Diagnosis Client
Types
Psychiatric High
Substance High
Serious & persistent mental illnesswith substance dependence
Psychiatric Low
Substance High
Substance dependence with somepsychiatric complications
Psychiatric High
Substance Low
Serious and persistent mental
illness with substance abuse
Psychiatric Low
Substance Low
Mild psychopathology with
substance abuse
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Treatment Continued
Parallel: These intervention approaches focus on bothsubstance abuse and mental illness treatment at thesame time
Integrated: Treatments are delivered at the same time
(like the parallel approach) but are coordinated by thesame staff team members in the same treatmentsetting
Specific approaches with in these 3 philosophies include:
Biological: This is the psychotropic medication arm oftreatment and can be effective toward managingsymptoms of mental illness which in turn can facilitatetreatment of substance misuse
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Treatment Continued
Social and Psychological: This is a broad spectrumterm used to describe therapeutic techniques suchas:
Motivational Interviewing: Engaging in supportiveand directed conversation about individualsbehaviors and patterns that are designed to increaseintrinsic motivation to change
Cognitive Behavioral: weakening connectionsbetween life stressors and reactive/habitualresponses that are negative and destructive.
Self-Help Groups: This includes many 12-step groupsthat can instill peer support and self-discipline
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AOS Programs
Programs that offer Addiction-Only Services
Some addiction treatment programs cannot accommodate
patients with psychiatric illnesses that require ongoing
treatment, however stable the illness and however wellfunctioning the individual. Such programs are said to provide
Addiction-Only Services
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DDC Programs
Dual Diagnosis Capable (DDC) Programs
Dual Diagnosis Capable (DDC) programs routinely accept
individuals who have co-occurring mental and substance-
related disorders. DDC programs can meet such patients needsso long as their psychiatric disorders are sufficiently stabilized
and the individuals are capable of independent functioning to
such a degree that their mental disorders do not interfere with
participation in addiction treatment.
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DDE Programs
Dual Diagnosis Enhanced (DDE) Programs
DDE programs can accommodate individuals with dual
diagnoses who may be unstable or disabled to such an extent
that specific psychiatric and mental health support. monitoring
and accommodation are necessary in order for the individual to
participate in addiction treatment. Such patients are not so
acute or impaired as to present a severe danger to self or
others, nor do they require 24-hour, intensive psychiatric
supervision.
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The ideal
Client & professionals can see and access holistic service
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The reality
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Strategies forPsychopharmacology with
Persons who have
Co-Occurring Disorders
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PSYCHOPHARMACOLOGY PRACTICE
GUIDELINES
DUAL PRIMARY TREATMENT
ADDICTION PSYCHOPHARM
Disulfiram
Naltrexone
Acamprosate
Bupropion, Varenicline
Opiate Maintenance
Mood stabilizers?
Others? (Baclofen, etc.)
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PSYCHOPHARMACOLOGY PRACTICE
GUIDELINES
DUAL PRIMARY TREATMENT
PSYCHOPHARM FOR MI
Atypicals (?) and clozapine for psychosis
LiCO3 vs newer generation mood stabilizers
Any non-tricyclic antidepressant, particularly
SSRI, SNRI
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PSYCHOPHARMACOLOGY PRACTICE
GUIDELINES
DUAL PRIMARY TREATMENT PSYCHOPHARM FOR MI
Anxiolytics: clonidine, SSRIs, SNRIs, topiramate,other mood stabilizers, atypicals (short-term),
ADHD: Atomoxetine is probably first line.Bupropion, clonidine, SSRIs, tricyclics, then
sustained release stimulants.
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SAFETY Acute medical detoxification should follow same
established protocols as for individuals with
addiction only.
Maintain reasonable non-addictive psychotropicsduring detoxification
For acute behavioral stabilization, use whatever
medications are necessary (including
benzodiazepines) to prevent harm.
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APAKAH PRINSIP ASAS RAWATAN PENAGIHAN DADAH YANG BERKESAN? Prinsip asas rawatan penagihan dadah yang berkesan adalah:
1. Tiada rawatan tunggal sesuai untuk semua individu klien.2. Rawatan dan pemulihan perlulah mengikut keperluan klien yang unik.3. Kemudahan rawatan perlu sentiasa ada (tersedia).4. Rancangan pemulihan perlu dinilai dan dikaji semula dari masa ke masa.
5. Klien hendaklah berada dalam tempoh rawatan yang mencukupi.6. Kaunseling dan terapi tingkahlaku merupakan komponen yang kritikaldan berkesan dalam rawatan.7. Ubat-ubatan boleh membantu rawatan penagih dadah.
8. Dual-diagnosis perlu untuk penagih bermasalahpsikiatri.9. Detoksifikasi penting untuk menghilangkan kegianan.10. Motivasi dalaman dan luaran boleh membantu pemulihan.11. Status kepulihan klien perlu dipantau.12. Pengesanan HIV dan penyakit kronik perlu dibuat.13. Sistem sokongan sosial perlu untuk mengekalkan kepulihan