Zoned, Stoned And Blown - by Louis B. Cady, M.D. and Lisa Seif, LCSW, CADAC02 17 2010 Slideshare

“ Joyful Beginnings” – mixed media, January, 2004 Amy Musia – Evansville, Indiana www.ajmusia.com

Zoned, Stoned and Blown: The Emotional Tsunami of Psychiatric Disorders Coupled Chemical Dependency Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Professor – University of Southern Indiana Adjunct Clinical Lecturer – Indiana University School of Medicine Department of Psychiatry Child, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana Lisa Seif, LCSW, CADAC, CSAMS – CWI Therapist Director: Warrick County Drunk Driving and Drug Court Program Adjunct Professor – ITT Facilitator – Adventure Based Challenge Program for YOUTH FIRST

ADD – inattentive, without Rx ADD – inattentive, on Adderall Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA

Never mind the pictures. Adult ADD isn’t real, is it?
Study of 24 ADHD adults vs. 18 controls
Comparable on age, SE status, sex, handedness, education, IQ and achievement tests
MRI on 1.5 T Siemens scanner; image parcellation of neocortex into 48 gyral based units
Seidman LJ, et al. Biol Psychiatry. 2006 Nov 15;60(10):1071-80

Volumetric Adult ADHD study, cont.
Relative to controls, ADHD adults had:
Significantly smaller overall cortical gray matter
Smaller prefrontal cortex
Smaller anterior cingulate cortex
CONCLUSIONS:
Adults with ADHD have volume difference in brain regions in areas involved in attention and executive control.
These data, largely consistent with studies of children, support the idea that adults with ADHD have a valid disorder with persistent biological features.
Seidman LJ, et al. Biol Psychiatry. 2006 Nov 15;60(10):1071-80

ADHD – A Family Practice Perspective Montano, B – Un. Of CT Medical School Dept of Family Practice
Adult prevalence rate 4.5%
Most adult sufferers have not been properly diagnosed or treated.
They have at least one comorbid psych. d.o.
This d.o. may offer the first clue of ADHD
Comorbidities may confound the diagnosis.
Use of available standardized rating scales helpful.
Primary caregivers encouraged to dx and tx.
J Clin Psychiatry. 2004;65 Suppl 3:18-21.

ADHD: Course of the Disorder Hyperactivity Impulsivity Inattention * Loss of productivity Tardiness, mistakes Disorganization Disruption of work flow — Age —

Horrigan J, et al. Presented at 47 th Annual AACAP Meeting: October 24-29, 2000. New York, NY.

Kids and Adults – Differences in HYPERACTIVE domain
AS A CHILD:
Squirming, fidgeting
Cannot stay seated
Cannot wait turn
Runs/climbs excessively
Cannot play quietly
On the go/driven by motor
Talks excessively
Blurts out answers
Intrudes, interrupts others
AS AN ADULT:
Work inefficiencies
Can’t sit through meetings
Cannot wait in line
Drives too fast
Self-selects very active job
Cannot tolerate frustration
Talks excessively
Makes inappropriate comments
Interrupts others
Sources: DSM-IV (TR). APA 2000:85-93) Weiss MD, Weiss JR. J Clin Psychiatry 2004;65(Suppl 3):27-37.

Persistence of ADHD Into Adulthood
ADHD is a heterogeneous disorder associated with considerable disability and comorbidity that, in many cases, persists into adulthood 1
Some studies have found persistence as high as 36.3% 2
Mood, anxiety, and substance use disorders are the most common comorbid disorders in adults with ADHD 3
Current prevalence of ADHD persistent into adulthood 4.4% 4
Much of the treatment of adult ADHD can be based on experience in treating children/adolescents 5
Barkley et al. J Abnorm Psychol . 2002;111:279-289.
Kessler RC et al. Biol Psychiatry 2005 June;57(11):1442-51. [retrospective review of 3,197 14-44 yo respondents in NCS-R]
Biederman et al. Am J Psychiatry . 1993;150:1792-1798. 4. Kessler et al. Am J Psychiatry. 2006;163(4):716-23 . 5. Dodson WW. J Clin Psychol . 2005;61:589-606.

Occupational functioning of ADHD children followed into adulthood
most are employed full time
lower occupational status and SES
change jobs more frequently
more firings and layoffs
more conflict with supervisors and coworkers
employer ratings of ADHD adults lower in
completing work
independence
need for supervision
great probability of being self-employed (Mannuzza)
Weiss & Hechtman, 1993; Mannuzza et al, 1993, Barkley et al, 1990

Unemployment, underemployment are also problems…

What happens if ADHD isn’t treated?

Psychiatric disorders (lifetime) in adults with ADHD [multiple sources, % is estimated; N.B. – this is WITHOUT TREATMENT GROWING UP ]
Substance use disorders (all) 50%
Anxiety disorders 40%
Major depression 35%
Learning disabilities 20%
Bipolar disorder 10%
Antisocial disorder 10%

% of patients with ADHD presenting with OTHER psychiatric disorders [“Reverse comorbidity”]
Major depression: 20% have ADHD
Bipolar disorder: 15% have ADHD
Generalized anxiety disorders: 20% have ADHD
Substance abuse: 25% have ADHD
Sources: Alpert, et al. Psychiatry Res. 1996;62:213. Nierenberg et al. Presented at the 157 th Annual Meeting of the APA 2002. Faraone S et al. J . Affect Disorder 2000; 58:99. Wilens. Psych Clinic N. Am 2004.

Earlier Initiation of Smoking with ADHD 237 6 to 17-year-old boys 0.6 0.5 0.4 0.3 0.2 0.1 0 Smoking probability 0 2 4 6 8 10 12 14 16 18 20 22 24 P <0.003 ADHD n=128 Control n=109 Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44. 4 year follow-up

SUD’s in Adolescents with ADHD
75% - non medicated ADHD (n=19) [p<.001]
25% - medicated ADHD (n=56)
18% - Non-ADHD control (n=137)
Biederman et al Pediatrics 1998; 104:e20

Pharmacotherapy Significantly Reduces Substance Abuse in Adults with ADHD Biederman J, et al. Pediatrics. 1999;104:e20-e25. 40 30 20 10 0 % of study population Unmedicated ADHD Medicated ADHD Control 32 12 10 P <0.001 (N=56) (N=19) (N=137) 3-fold!

Increased Lifetime Substance Abuse in Untreated Adults with ADHD Biederman, et al. Biol Psychiatry. 1998;44:269-273. Lifetime rate of substance abuse in referred ADHD adults 0 10 20 30 40 50 60 55% Control (n=268) ADHD (n=239) 27% P <0.001

The 3 Big Reasons for substance abuse – Louis B. Cady, M.D.
Looking for help
Something to make their minds work better
Looking for something to CALM DOWN with
Looking for Mr. Good-Drug
Something to take AWAY the pain of failure and lack of performance
Hanging with the WRONG CROWD
“ like attracts like”; “losers attract losers”

AD H D vs. Bipolar Disorder
Mood lability
Bursts of energy
Restlessness
Talkativeness
“ Racing thoughts”
Impatience
Impulsivity
Impaired judgment
Irritability
Chronic course
Lifelong impairment
Genetic clustering
American Psychiatric Association. DSM-IV ; 1994:78-84, 350-363. 12 Features in Common:

ADHD vs. BPD in Adults
ADHD
Constant
Lifelong
Moods triggered
Moods congruent
Instantaneous shifts
Thoughts “jump”
Family Hx of ADHD
Bipolar
Cyclical
Later onset (mean, 26 yrs)
Moods untriggered
Moods incongruent
Gradual shifts
Thoughts “race”
Family Hx of bipolar
STEP-BD reports at least 19% comorbidity of bipolar disorder and ADHD. STEP-BD = Systematic Treatment Enhancement Program for Bipolar Disorder. American Psychiatric Association. DSM-IV ; 1994:78-85, 350-363.

ADHD Comorbidity with bipolar disorder – how to tell’em apart
Adults with ADHD
Lack severe mood lability symptoms
Moderate impairment in functions
Adults with ADHD + BPD
Prominent mood lability (think “rage-aholic”)
High rates of hyperactive/impulsive symptom
Episodicity of mood and overall symptoms
Severe impairment in function
Wilens et al. Biol Psychiatry 2003;54:1

How to Commit Malpractice
Send a bipolar/ADHD patient into orbit with stimulants!
Potential errors:
Failure to take a good enough history
Failure to ask “the question”
Failure to start REALLY LOW on ADD medication

“ Strattera [coupled with Prozac or Paxil] has been great for our admissions.” -Dr. William Beute, MD Pine Rest Campus Clinic Grand Rapids, MI April 21, 2004 [quoted with permission] The “Take Home” – don’t prescribe a 2D6 drug-drug interaction.

OTHER DIAGNOSTIC STUFF…..

LOW ENERGY – frequently occurring with depression. A “no duh,” KNOWN finding.
People with depression have LOW ENERGY….
So you….
Prescribe ("SIG:") "E - caps"!!

Depression & Anxiety Dx in 1 Easy Lesson
DEPRESSION SIG: E- CAPS!
Sleep
Sadness
Interest loss
Guilt
Energy
Concentration
Appetite
Psychomotor Sx
Suicidal thinking
Gen. ANXIETY D.O.
Somatic Sx (“ energy ”,etc.)
WORRY
Irritability
Concentration
Keyed up
Insomnia (“sleep”)
Restlessness
SWICKIR is Quicker: Worry + 3 = GAD (Baughman) 5of 9 with 1 of 2 x 2 weeks

Depression & LOW ENERGY in One Easy Lesson
DEPRESSION SIG: E- CAPS!
Sleep
Sadness
Interest loss
Guilt
Energy
Concentration
Appetite
Psychomotor Sx
Suicidal thinking
OTHER FREQUENT CAUSES:
Hypothyroidism
Sub-syndromal or other
Low DHEA
Exhausted adrenals
(can check with 4 cortisol levels)
Low testosterone
Low micronutrients and vitamins
(low growth hormone)
5 of 9 with 1 of 2 x 2 weeks w/o other causes!!! MUST EXCLUDE OTHER CAUSES, as well as treat for presumptive diagnosis.

Continuum of Depression and Anxiety Anxiety disorders Stahl SM. J Clin Psychiatry . 1993;54(1 suppl):33-38. Major depressive disorder Comorbid depression and anxiety

Depression & Anxiety By the Numbers:
Depression
2 – 4 % of US population/year
Lifetime:
21% of women
13& of men
ANXIETY
4-8% of US population/year
60% with anxiety disorder come in with somatic symptoms!
Adapted from Katon, W. Jounrl Clin Pysch, 1990, Depression & Chronic Mental Illness; and - Kessler, R et al. Lifetime & 12 Month Prevalence of DSM-IIIR Psychiatric Disorders in the U.S. (Ntl Comorb. Study). Arch Gen Psych, Jan 1994, 8-19 . Myers, Weissman, Tischler. Six month prevalence of psychiatric disorders in three communities. Arch Gen Psych 1984; 41:959-967. Goldberg, Bridges. The diagnosis of anixety in primary care settings. Br J Clin Pract Symp, 1985; 38 (suppl):28-33

Overlapping Symptoms of Depression and GAD Major Depressive Disorder (MDD) Generalized Anxiety Disorder (GAD) Depressed mood Anhedonia Appetite disturbance Worthlessness Suicidal ideation DSM-IV-TR. Washington, DC: American Psychiatric Association. 2000. Sleep disturbance Psychomotor agitation Concentration difficulty Irritability Fatigue Worry Anxiety Muscle tension Palpitations Sweating Dry mouth Nausea

Adrenal Burnout

Diagnostic Pearls - Cady
How’s work?
How has your employment history been?
How’s your mood? Your marriage (relationship)?
How was school for you?
Are people nervous driving with you?
Are there periods of time when you have too much energy for no particular reason ?
Do you ever have to have a beer at the end of the day to relax?
[gently lead in to other substances, especially stimulants that may have a CALMING effect]
“ Have you ever taken any of your child’s ADD Rx?”

An Higelian Dialectical blend of therapeutic alternatives - Cady
Thesis: “you can’t be treated if you are using .”
Anti-thesis: “ Doc, I can’t stop using unless you can do something for me.”
Synthesis: “Let’s see if we can work something out.”
“ crossover titration” or replacement of illicit substance with RATIONAL alternative (e.g. – cocaine with Bupropion or atomoxetine; marijuana with clonazepam or Oxycarbazepine (Trileptal ®). Must be willing to ‘GET SOBER.’
REFINEMENT of pharmacotherapy as case unfolds
Willingness to get into AA/NA and GET A SPONSOR, and WORK STEPS – if appropriate.
If you don’t want to fool with it, REFER, don’t just brand them as “hopeless” or untreatable.

Methylphenidate Efficacy in Adult ADHD Controlled Comparison of MPH in Adult ADHD * P <.0001. Adapted with permission from Spencer et al. Arch Gen Psychiatry . 1995;52:434-443. Baseline Week 1 Week 2 Week 3` ADHD Rating Scale Score Placebo Subthreshold ADHD MPH * * * N=23 42 36 0 6 12 18 24 30

Efficacy of a Mixed Amphetamine Salts Compound in Adult ADHD Adapted with permission from Spencer et al. Arch Gen Psychiatry . 2001;58:775-782. 40 30 20 10 Baseline Week 1 Week 2 Week 3 ADHD Rating Scale Subthreshold ADHD P <.001 P <.001 Placebo Mixed amphetamine salts compound N=27 DSM-IV ADHD Symptom Checklist

Atomoxetine Efficacy in Adult ADHD CAARS-Inv ADHD = Investigator-rated Conners Adult ADHD Rating Scale. Adapted from Michelson et al. Biol Psychiatry . 2003;53:112-120. CAARS-Inv ADHD Total 32 30 28 26 24 22 Baseline Week 2 Week 4 Week 8 Week 6 Week 10 Placebo Atomoxetine * ** † † † *P <.05; ** P <.003; † P ≤.001.

Current medications available for Adult ADHD
Atomoxetine Nov. 2002
Mixed amphetamine salts XR August 2004
D-methylphenidate XR June 2005
Methylphenidate OROS June 2008
Lisdexamfetamine June 2008

Response to Psychostimulants - Arnold et al. J Attention Dis. 2000;3:200. Best Response (Percent) AMP MPH Equal response to either stimulant Meta-analysis of Within-Subject Comparative Trials Evaluating Response to Stimulant Medications 28% 16% 41% AMP=Amphetamine (Adderall ® , Dexedrine ® , Dextrostat ® ); MPH=methylphenidate (Ritalin ® , others).

Treatment Pearls
Don’t be afraid to treat/refer. You can actually be sued if you DON’T (and you have obtained the history, and then a catastrophe occurs).
RX: Pick the one best agent in each stimulant class
Sustained effect throughout the day best
RX: Start with the LOWEST PILL STRENGTH IT COMES IN (or DILUTE IT (Vyvanse).
Go up from there.
Push as high as needed, within PI.
If in doubt, refer.

People at Risk
PSYCHIATRIC
ADHD
Depression
Anxiety disorders
Bipolar d.o.
Self-described usage
FAMILY HISTORY
(parent OR grandparent = 4 X the risk!!)
LEGAL
High risk/high need
Low risk/no need
PSYCHOSOCIAL
PERSONALITY TRAITS

“ The phenomenon of craving” William Duncan Silkworth, MD

David L. Ohlms, MD
“ Few other major primary diseases produce the range of emotional and physical complications caused by addiction to the drug, ALCOHOL.”
“ It is destructive to practically every major organ system in the human body compared to other drugs.”

“ The fact that the majority of people can drink without losing control reinforces the [erroneous] opinion that there is something very wrong with the basic character of those who d o lose control.”
- Cady & Seif

People at Risk
High Risk/High Need
Middle stages of CD
Unemployment
UnEMPLOYABLE
Undereducated
Few law-abiding friends
No stable relationship
Hopelessness, homelessness
Low risk/low need
Early stages
Employed
Good support system
Has a vision of the future
Spiritual foundation
Able to conceptualize recovery concepts
Motivation to change

People at risk – legal woes
Legal
Repeat drunk driving
Repeat drug offenses
“ Petition to revoke”
Failed urine drug screens
Antisocial behaviors (driving on suspended license, etc.)

Psychosocial:
History of “ODD”, conduct problems as child
“ terminally unique”
Impatient (low impulse control – ADHD?!)
Resistant to change
No life purpose
no family support
No goals
No purpose
No pleasure

Risky behaviors
“ people places and things”
“ lying, cheating, and stealing”
Failure to follow through on recovery maintenance activities
Never grasping “step #1” in AA
Not dealing with dual diagnosis issues (medication noncompliance)

Patients at risk
Family biology/genetics
(psychiatric AND/or addictive disorders)
Unenlightened, “un-shrunk” state:
“ euphoric recall” never dealt with
“ Dry” but not “Sober.” (Not in recovery.)
“ Hard wired” issues - Learning disabilities
Isolation – social, psychological, emotional

RELAPSE PREVENTION STRATEGIES
“ Alcoholism doesn’t go away, like diabetes heart disease, cancer, blindness, paralysis… sooner or later you have to accept that you have no control over the PHYSICAL abnormalities. Counseling and support groups can’t change the way our bodies metabolize drugs, alcohol, and substances.”
- Cady and Seif

Step ONE!!
“ We admitted that we were [are?] powerless over alcohol – and that our lives had become unmanageable.”

What happens when you slip?

Key concepts of relapse prevention
Alcoholism/ CD don’t go away
Ongoing recovery is great but a drink can undo it.
Need to ACCEPT no control over this “physical allergy” (Silkworth)

Medication/Meditation
MEDICATION:
INITATION:
Axiom: “Treat the problem, not the symptom.” (Cady)
“ Jump on it; don’t just look at it.” (Cady)
MAINTENANCE:
Drug screen- “Trust, but verify.” (Reagan)
MEDITATION:
“ the principle of mindfulness”
Time alone for “reprogramming” – retrain the brain into a “sober brain”
Learn social and relaxation skills

Medication CONDITION CONFOUNDS APPROPRIATE INAPPROPRIATE ADHD Prev. Meth, Cocaine Strattera, Intuniv, Bupoprion Ritalin, Adderall, Stimulants ADHD EtOH, MJ – to calm down Stimulant? sedatives Anxiety, Depression, ADHD Alcohol, MJ TREAT THE PROBLEM, NOT THE SX – eg., SSRI’s, focused Rx for ADHD which can cause anxiety, detc. “ brain dead benzo’s” (Xanax, Klonopin) Bipolar Mood stabilizers “ downers”(BZD’s) Chemically dependent Uppers/downers: Red Bull, etc.

Know When to Fold’Em

Team Approach
COMMUNICATION between members:
Physician (frequently not a psychiatrist)
Social worker/therapist
Probation/parole officer (judge)
School or supervisor, if appropriate
Cross training:
MD’s should know about recovery issues
CD workers – should know about Rx
TIPS:
Release of information’s need to be signed
Maintenance of collegiality

"If I hadn't believed it, I wouldn't have seen it." - Yogi Berra Personal collection Louis B. Cady, M.D.

“ For me, the practice of medicine has opened the door to the greatest adventure in life. Medicine is like a hallway lined with doors, each door opening into a different room, and each room opening into another hallway, again lined with doors. Medicine is always wonderful and never will be finished. ” - Charles H. Mayo, M.D.

Thanks for coming! Please fill out evaluations!  Contact info: Dr. Cady and Lisa Seif, LCSW – 812-429-0772 ( [email_address] )

Zoned, Stoned And Blown - by Louis B. Cady, M.D. and Lisa Seif, LCSW, CADAC02 17 2010 Slideshare

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Zoned, Stoned And Blown - by Louis B. Cady, M.D. and Lisa Seif, LCSW, CADAC02 17 2010 Slideshare — Presentation Transcript