Zoned, Stoned And Blown Pain Psych R X And C D Cady At Oliver

Zoned, Stoned and Blown: The Emotional Tsunami of Psychiatric Disorders Coupled with Pain Disorders & 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

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

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.

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

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.

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, or just THE PAIN
Hanging with the WRONG CROWD
“ like attracts like”; “losers attract losers”

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

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 & 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. Journal Clin Psych, 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

How do you spell RELIEF? Diagnosis Symptoms Substance/Abuse Depression Sleep problems Downers, pain Rx EtOH Depression Concentration Uppers, stimulants Depression FATIGUE Uppers, stimulants Anxiety Worry, tension Downers, pain Rx, EtOH Adrenal fatigue FATIGUE Uppers, stimulants

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.

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).

Concepts in Recovery and Sobriety Maintenance co-developed with Lisa Seif, LCSW, CADAC, CSAMS – CWI Therapist

“ The phenomenon of craving” William Duncan Silkworth, MD

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
Don’t treat a SYMPTOM with a medication or mind-altering substance that’s not designed to work for it.
Ongoing recovery is great but a drink can undo it.
Need to ACCEPT no control over this “physical allergy” (Silkworth)

Medication strategies (Cady) CONDITION CONFOUNDS APPROPRIATE INAPPROPRIATE ADHD Prev. Meth, Cocaine Strattera, Intuniv, Bupoprion Ritalin, Adderall, Stimulants ADHD EtOH, MJ , pain RX – to calm down Stimulant? sedatives Anxiety, Depression, ADHD Alcohol, MJ, PAIN RX 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, (?) atypicals (?) “ 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: Louis B. Cady, MD – 812-429-0772 ( [email_address] )

Zoned, Stoned And Blown Pain Psych R X And C D Cady At Oliver

by Louis Cady, MD on Feb 27, 2010

Accessibility

Categories

Tags

Upload Details

Usage Rights

1 Embed 1

Statistics

Zoned, Stoned And Blown Pain Psych R X And C D Cady At Oliver — Presentation Transcript