rawatan klien dua diagnosis

7/27/2019 RAWATAN KLIEN DUA DIAGNOSIS

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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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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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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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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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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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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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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

rawatan klien dua diagnosis

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