 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome you to today's presentation on the continuum of co-occurring disorders. We're going to look at a couple cross-cutting issues in addition to the continuum of co-occurring. But what we're really going to focus on is exploring the varying courses of addiction and mental health disorders because they don't always start at the same time. They don't always take the same path. Some people start to have a problem with depression or addiction and, you know, it doesn't end up becoming clinically diagnosable. Others, you know, it becomes an issue and they have one episode. Some people have multiple episodes. So we're going to take a look at what might influence that. And then we're going to really look at some interventions in order to help people live their highest quality of life. So treating someone with a mental health or personality disorder complicates the picture and increases the risk of concurrent disorders such as addictive and mood and personality disorders. One of the things we are looking at is if you are a mental health clinician, when you're treating someone, paying attention to potentially the upsurgeance of symptoms for addictive or other mood or personality disorders. If you are, you know, again, a mental health clinician, you also want to assess for those at the very beginning. People with more chronic or longer standing mental health issues are at a much greater risk for misusing substances or developing addictive disorders. And I want you to focus on the misusing substances part because we know, and we talked about this, when you are or when people are using substances, even if they're not abusing substances, it monkeys with their neurotransmitters. And that monkeying, so to speak, can lead to mental health symptoms. It can lead to higher anxiety. It can lead to depression, whether it's when they're on the substance or when they are recovering from it. It can also lead, like in the case of, for example, gambling addiction, maybe they're not using a drug, but they're engaging in an addictive behavior. You know, a lot of gambling takes place late at night, so they may be staying up late and not getting enough sleep, which can predispose them to situations which may produce depressive symptoms. So we do want to take a look at our clients as a whole and make sure that they are not engaging in behaviors that are going to increase their risk for the development of problems and that they aren't developing other problems, you know, which could just occur because of, you know, life itself. So for effective differential diagnosis, we need to make sure when we're addressing our mood disorders to remember that both substance use, you know, while you're on it and discontinuance may be associated with depressive symptoms. So if you're working with someone who is misusing alcohol, even if they're not an alcoholic, some of their depressive symptoms may be a result of neurotransmitter issues that may resolve once the body has adjusted to not having the alcohol in it. Either way, you know, chicken or egg, you've still got a person that's presenting with depressive symptoms, so we need to address them, but knowing what is causing the neurotransmitter imbalance is important in terms of long-term care planning because someone whose symptoms will likely remit once their body balances out after being sober for a while has a very different treatment course probably than someone who has had depressive episodes all of their life. So we want to take a look at that. Acute or manic or anxiety symptoms can be induced or mimicked by intoxication with stimulants, including high levels of caffeine. So think about your energy drinks right now, and they actually have an energy drink. It just broke my heart. They actually have an energy drink online for sale that's called cocaine. Wicked stimulants in a lot of the energy drinks that are sold over the counter. Steroids, hallucinogens, and polydrug combinations. So combining, for example, decongestants with caffeine can present symptoms of mania or, well, hypomania probably, or anxiety. And if the person is bipolar or does have the risk of becoming bipolar, use of these substances may trigger an acute episode or trigger their first episode. Withdrawal from depressants, opioids, and stimulants all have potent anxiety symptoms. So, you know, when we're thinking about stimulants, we're still thinking about not only your illegal stimulants, so to speak, but we're also thinking about caffeine and nicotine. Medical problems and medications can also produce symptoms of anxiety and mood disorders. So when we're making our differential diagnosis, we want to make sure that we're taking all of this into the picture, so we're making sure that we're getting the person any wraparound services that they need, and we're addressing the root causes of their mood disorders while also watching, alertly, for symptoms of new mood disorders. Those who use substances, misuse substances, tend to fall into some pretty predictable categories if they're self-medicating. People with depression tend to favor some sort of stimulation, give them some energy. People with anxiety tend to favor things that are going to help them be more sedated, but that's not always true. And remember, alcohol is tricky, because the first part after they drink produces your depressive symptoms, your relaxation, but as the alcohol leaves the system, anxiety levels increase markedly. So, you know, alcohol is kind of interesting when we look at why and when people use it. What causes these things? Well, genetics account for 30 to 40 percent of the variability of mood disorders, and they found that environment, especially multiple adverse childhood experiences, and overprotective or disengaged parents can cause a significant other part of it. Now, they include temperamental, the neuroticism dimension of personality as part of genetics, but people who are high in the dimension of neuroticism, when we talk about the big five personality traits, tend to be at a much greater risk for the development of mood disorders. So, when we're doing our assessment, we want to ask about adverse childhood experiences and how the person perceived those, because, you know, I went through the Adverse Childhood Experience Survey and I'm thinking to myself, you know, some of these things are just commonplace anymore and not everybody who comes from a family where there is a divorce or domestic violence or whatever necessarily has a negative outcome. Some children are able to accommodate to it and work through it, because they had other social supports or whatever the case may be. But we want to ask the person, what did this event mean to you? We want to investigate the parenting style. If the parents were enmeshed and oppressive, that's going to create certain characteristics and certain kind of flashback. And if the parents were disengaged, it may create more anxiety and more difficulty developing secure attachments. But temperamentally, we're going to look at neuroticism. And these are people who tend to be moody and experience more often than the average person. Anxiety, worry, fear, anger, frustration, envy, jealousy, guilt, depressed mood, and loneliness. So pretty much your dysphoric emotions. So they tend to be more unhappy more of the time. They tend to respond worse to stressors and are more likely to interpret ordinary situations as threatening and minor frustrations as hopelessly difficult. So this is really important when we are thinking about how to intervene with people. So people who tend to be high on neuroticism, if they tend to interpret ordinary situations as threatening, we want to use the challenging questions and ask them, you know, what is the evidence for and against this? Are you basing it on emotional reasoning or factual reasoning? And are you considering the whole situation or just a little aspect? So encourage people to look at and objectively evaluate how threatening the situation is. And encourage people to examine minor frustrations when they happen and figure out why they're experiencing them as hopelessly difficult. Why are they magnifying? Think about your cognitive distortions, magnification and exaggeration. So something that's not that big of a deal is just completely overwhelming. Now, if the person already has a bunch of anxiety going on, you know, that could be the straw that broke the camel's back, so to speak. So we don't want to negate how the person's feeling, but we want to help them look at, in the big scheme of things, how challenging is this? How overwhelmingly difficult is it? And what is contributing to you? What vulnerabilities exist that are contributing to you feeling like this is totally overwhelming? Interestingly, people who are high in neuroticism tend to be more self-conscious and shy, so they're more withdrawn and have trouble controlling urges and delaying gratification. These are things we want to remember, but we also want to remember that each individual is different. So we want to help people address their presenting issues, which could make them more vulnerable to depression and anxiety. Other things that we want to consider when we're diagnosing and to remember is that sometimes depression is situational, and, you know, that would fall more in the adjustment disorder because, you know, their house burned down, or they just went through a hurricane or something and it was exhausting and overwhelming and they are just, they can't see the forest for the trees right now. Other times it's episodic and there's no easily identifiable trigger. We can't say there's a grief issue there or there's a, you know, there was a natural disaster. Something happens and people have these episodes of depression or anxiety. When it's situational and people can point to something and say that triggered it, a lot of times they feel like they've got more control. They feel more empowered, which helps us a lot in the treatment process and their prognosis is better. When people have episodes that seem to come from out of the blue, it's a lot more frustrating and they may feel a lot more powerless. As clinicians, one of the things we can do is, again, help them look at the big picture and really assess what is going on that leads up to a time when an episode may happen. We want to look at their physical health, their nutrition, their sleeping, their socialization. And we also want to look at what's different during the times when you're not depressed. And sometimes it can be something internal. For example, hormones, if somebody has premenstrual dysphoric disorder, then they may be highly sensitive. And maybe if they are start taking birth control pills or some sort of hormone replacement, it could throw them into an episode. They could be really sensitive to certain medications. It's important to encourage them to look as closely as needed to figure out some things that may be related to their depression. Remember, seasonal affective disorder affects a lot of people. So maybe their depression tends to be worse during the winter when it's dark out a lot. Or if there's been a stretch where it hasn't been sunny for like four, five, six, seven days. There's a much greater rate of seasonal affective disorder in those states, especially like in the Upper Northwest, that have a lot of rain and a lot of cloudy days versus somewhere like Florida, which is the Sunshine State. Doesn't mean they don't have depression. It just means seasonal affective disorder is different in its prevalence in those two areas. But encouraging people to look at this gives them hope that, hey, you know, this isn't something that's completely uncontrollable that I just kind of got to wait for it to happen. There are things I can do and there are ways to prevent it. The continuum ranges from mild to moderate to severe to remission. And remission is important because when we look at mood disorders like major depressive disorder, we're looking for a period of greater than two months without symptoms. Now, two months seems like awesome to somebody who's felt depressed for a really long time. But two months really isn't that long in the big scheme of things. So if somebody has two months of remission and then all of a sudden they wake up and they're, you know, feeling really depressed again, it may feel like somebody dropped a brick on their head. So we want to recognize that and recognize that people who tend to have longer lasting episodes or more frequent episodes of mood disorders or addiction, tend to have more issues with depression and frustration and a sense of hopelessness and helplessness. So anything we can do to empower these clients to reduce the frequency or intensity of their episodes will help a lot. And that's another thing I point out to some of my clients is, you know, when you have an episode. Yes, you're having another one right now and it sucks, no doubt. However, on a scale of, you know, one to five, one being really mild, five being really severe, where is your continuum? Or where is your symptoms right now? And I want to look for a reduction in intensity. I really want to see them being able to catch it earlier. Noticing when they start to get depressed earlier so they can intervene earlier. Most of the time people don't just go from being happy as a clam to clinically depressed, literally overnight. So there's a little bit of wiggle room in there, a little bit of time where we can say, whoa, something bad's fixing to happen. Median age of onset is 13 for social anxiety. Now this isn't surprising. This is the beginning of high school. So it's not surprising that a lot of adolescents experience some episodes of social anxiety. Median age of 30 for generalized anxiety disorder. And again, think about what's going on at 30. This is when your career starting to take off, you're probably having children, you know, buying houses, doing all kinds of adulting sort of things. And it can get overwhelming really fast. And there's, you know, all these other pressures because you've got bills coming in and other things. Puberty is when people generally experience their first major depressive disorder. And they define puberty as age 10 to 14. So we may be seeing someone who had their first depressive episode at the age of 10. That's fourth grade. So, you know, that in and of itself is heartbreaking, but we want to pay attention to that. And recognize that it's important to address the fact that the long standing major depressive disorder can be more problematic. Generally, the content of anxiety for generalized anxiety disorders is age appropriate and changes over the lifespan. Now, a lot of times we'll have people that present with both depression and anxiety, and it makes sense. I mean, anxiety, fight or flight, they're revved, depression, hopeless, helpless, can't defeat whatever this threat is. So eventually they just kind of start shutting down. Eventually they hit that point of exhaustion. So it makes sense that someone who has generalized anxiety disorder may have concurrent episodes of major depression. And we want to assess for that. Again, what's causing the depression? Is it anxiety and being too revved or is it, you know, hypothyroid or, you know, what's going on? Because we need to figure out where the break in the system is in order to help them really address it long term. Depression diagnosis requires five out of nine of the symptoms, which if you've ever done the math results in 126 possible presentations. So, and I point this out to clients so they understand that what works for Tom, Jane and Mary is probably going to be different for each one of them. Because everybody often presents differently with their depression. What agitation looks like for you may be different than what it looks like for Tom. Or maybe Tom doesn't have any problems with his eating when he's depressed or is sleeping for that matter. But he does have a lot of guilt symptoms and lack of pleasure. So we don't want people to think that depression looks the same for everybody. In major depressive disorder, the first episode presentation is quite variable. Some people, when they have their first episode, they never achieve remission of more than two months. I'll just sit with that for a second. This is major depressive episode, not recurrent depressive disorder, dysthymia, what we used to call it. That's pretty intense to never achieve a remission of two or more months. Other people may have the first episode at last a couple of weeks and they may go years between episodes or never have another episode. So it's important to pay attention to what's going on there. Another thing that triggers depression, I mentioned hormones earlier. When a person, when a woman gives birth, hormones go through this skyrocket changey thing. But when they quit breastfeeding, so if they never breastfeed, then it's not an issue. But if they nurse for any period of time, then when they quit breastfeeding, they're also going to go through another hormone roller coaster for a little while. So people who are prone to postpartum depression may experience it, you know, bimodally at least. And, you know, think about postpartum depression. What else goes on when you've got a new baby at home? You're not sleeping, you're not eating, and you're pretty lucky if you get a shower every other day sometimes. So we want to take all this into consideration and normalize it for people to help them understand why they're feeling the way they are. Recovery for most people with mood disorders begins within three months of onset for two out of five and within one year for four out of five. So thinking about the clients we have for, you know, not quite half, they should really start feeling significantly better in about three months. So people who are expecting to feel better in two, three weeks are setting themselves up for frustration. People to realize, you know, let's give it three months, let's look at what's going on. Even if they're just taking an antidepressant, it takes a good six weeks for that medication to get into their system. So people need to recognize that it's going to take some patience. And within one year for the four out of five. So you still have 20% of people there. One out of, what is that? One out of every five, yeah, one out of every five. Can't even do math today. Who is still experiencing symptoms one year after they start treatment. Ouch. That is, you know, I can see where people could be really frustrated and looking for some sort of relief, which is where addictive behaviors may come in, which is where suicidal behaviors may come in. People just can't keep living that way and they need to try to make it stop somehow. So paying attention to the duration is important. When people experience recovery, the longer the recovery period they found the lower the chance of recurrence. So if they have had a depressive episode once five years ago, the chance of them having another one is much smaller. Unless it's triggered by environmental events or something than someone whose last depressive episode was, you know, three months ago. So we do want to be aware if someone we're working with has a history of multiple episodes and how long is their typical remission period. That'll give us some clues about when the next one may be coming. And, you know, if another one's coming in, in, in the near future, we can start helping people prepare for it. Early onset of persistent, persistent depressive disorder, which is what we used to call dysthymia is correlated with a higher incidence of developing personality and addictive disorders, according to the DSM five. So if you remember back to diagnosis 101 that, well, at least that I went through back with the DSM three TR. Whoops. We used to think that personality disorders were largely genetically based and started presenting themselves in early, early adolescence at the latest. Now we're saying, you know, personality disorders can develop later on, and early onset of persistent depressive disorder is correlated with the development of that during even late adolescence and early, early adulthood. Those with chronic episodes or long standing symptoms have higher risks of developing concurrent mental health and addictive disorders. The general course for mood disorders people start having mood symptoms. They may start having social problems due to their mood symptoms, they're irritable and cranky and no fun to be around their fatigue all the time, and they start, you know, not wanting to hang out with people not wanting to go do things. They start experiencing depression anxiety and even grief about their mood symptoms. They may feel a sense of loss because they're not able to do what they used to do because they just don't have the energy or it hurts too much. They start experiencing sleep disruption and exhaustion when they're that tired all the time. A lot of times they're sleeping more, but not sleeping well. So you start seeing as disruption of the circadian rhythms, which leads to greater exhaustion and more reduced involvement in important activities such as work, family and even recreation. So the things that are important in their life, they just don't have the energy to do they don't have the desire to do they don't have the motivation to do. They start withdrawing from social relationships and they have an increase in mood symptoms because that if it was because of depression they start getting depressed and feeling hopeless and helpless to address the depression. Same thing with anxiety. So we see that it's this negative downward circle that can happen. The good thing is as clinicians we can intervene anywhere along that way. Increase social support from, you know, like others and you know this can be online social support if the person can't get to support group meetings or just doesn't have the energy to right now. We can help them address their irritability and develop distress tolerance techniques, you know, really look at what that irritability is about. We can help them address their grief about their loss of functioning right now and their frustration over being depressed and anxious. Help them look at that figure out, you know, acknowledge that they feel it, you know, we're not going to unfeel it. That's how you feel right now. But what can you do to improve the next moment? How can you start moving towards those things that are most important to you? We can educate them about good sleep patterns and sleep hygiene practices, including having plenty of bright light around until it's time to go to sleep. And then when it's time to start winding down having a sleep routine to help them get back get their circadian rhythms back in rhythm. With some of this, they should start getting back more energy and we can encourage them to make an effort, make a goal, make a plan to start getting a little bit more involved in the things that are important to them again. And, you know, maybe one a week, we're not talking something every day, that's too much to start out with. So we want to make sure they set reasonable goals and encourage them to identify those social relationships that are helpful. And what can you do in those relationships? What kinds of activities can you do that aren't overwhelming right now? You know, maybe going out to a club or going out to dinner because you have to get all gussied up and stuff. That's too much. But maybe your friend could come over and you could make dinner together or just watch a movie. So there's still social connection without all of the pressure and extra energy expended getting ready and going out and doing things. On the other hand, if the person you're working with is an extrovert, they may benefit and draw energy from getting out and being around other people. Even if it's just going to a movie theater, they may get some energy from being outside. So asking people, you know, what helps and what helps you feel better and start integrating those things. Recovery begins when there's a desire for help and hope that recovery is possible. If people don't think it's going to work, then recovery is probably not going to happen very quickly, if at all, because they're going to yes, but everything. And that's how you know when somebody hasn't bought into the program, if every time you suggest something, there's a yes but. So there's no rapport. They're not really feeling the sense of connection and hope that this could work. They begin proper self care, including medical and psychiatric is needed. We always want to refer people for a full medical work up, including, you know, blood work and hormone checks to rule out some of the physiological causes of anxiety and depression. Appreciation of possibilities. So once people go and get a medical work up, get a clean bill of health or start addressing those issues. If they go to a psychiatrist to get on antidepressants or anti anxiety, maybe maybe not remember psychotropic only work for about 40% of people. But sometimes the placebo effect works with with a significant portion of the rest of the people and it can help give them a little bit of hope that things are going to start going in the right direction. It's a personal choice whether they want to get on meds, but they start getting some momentum. They start feeling like, okay, we're making some progress, at least ruling out what it isn't. Then we encourage them to start appreciating the possibilities of recovery. Let's get excited about where we're going. What does happiness or recovery look like for you? And you know, that's a 10. And I really want to know what is going to be going on in their life. What's going to be different? What's going to be the same? What are you excited about when you're not depressed anymore? And you know, that's a 10. Like I said, then I want to ask them, you're at a one right now. What do you need to do to move to a two? What does a two look like? So we're going to take baby steps along the way, but this gives them a goal they can accomplish this week. This gives them something they can start working on this week. The person starts getting social support. They start developing hope. They start developing some motivation and enthusiasm, and we can encourage them to reach out and start getting support from other people. Support groups are great, but even just integrating with their friends again can give them some encouragement and can reduce the isolation. Encourage them to take a personal inventory to decide what's important to them right now. This helps garner hope and determination so they have what happiness looks like to them. And then stepping back and going, you know, that's that's the big picture. But what is really the most important to me right now? And what can I do to make that happen? With that information, we can help them set and begin achieving achieving smart goals. Remember specific, measurable, achievable, realistic and time limited. This helps people develop self-efficacy and self-esteem. When they achieve these smaller goals, they start getting momentum that I think I can, I think I can. And they do something and they're like, wow, I did it. I can do this. So their resilience starts to kick in too. We can at this point start teaching and maybe even earlier, but distress tolerance and coping skills for current triggers. You know, even if you are somebody who, you know, does a lot of historical work, helping them figure out in the present, you know, whatever that is, that stuff is from the past. How is it impacting you in the present and how can you deal with it? So, you know, maybe you didn't have a good childhood. All right, can't change that. But we can change how it impacts you in the present. What do we need to do? We can help people start improving their interpersonal effectiveness and relationships. You know, taking those inventories, figuring out, you know, is the person able to communicate effectively? Are they able to set boundaries? Are they able to ask for what they need? And help them figure out how to develop healthy relationships. Their self-esteem will continue to increase and they'll have an increase in emotional and behavioral control. We're giving them the tools and they're starting to let some of the pressure off. Think about a pressure cooker. When they come to treatment, they are just their tops about ready to blow off. They are just at their wits end. So, anything could send them into a spiral, could send them into a tailspin, could be the straw that broke the camel's back. As we start helping them get hope and self-efficacy and a sense that they can achieve happiness and they can achieve recovery, that pressure from that pressure cooker is going down. So, as things come their way, they're like, you know what? I got this. Look at what I've already accomplished. I've got this. And we start to see a corresponding use of the new skills and increases in emotional and behavioral control. For personality disorders, you know, we want to look again and say, what is the function of these behaviors? And I do a whole class on personality disorders. We're not going to go really deeply into it right now. But from a developmental perspective, when you look at the behaviors characteristic of antisocial or borderline or any of the personality disorders, and you look at the history of the person, 99.999 times out of 100, you're going to find that the behaviors make sense from a survival protective learning perspective. This is what they grew up around. This is how they survived and protected themselves. So, remembering that personality disorders in large part are behaviors that are dysfunctional across multiple situations. Well, behaviors we can help attenuate. They're brought on partly by genetics. We find that personality disorders are transmitted in families. How much of that is learning? How much of that is genetics? They're not really sure. They do look again towards the dimension of neuroticism. Childhood trauma is highly correlated with the development of personality disorders. So, again, think about these symptoms and how is it these symptoms were functional to a six-year-old who experienced trauma. Verbal abuse, especially maternal, and I have the article linked over here. They did a study of 793 people, and those who experienced maternal abuse during childhood were more than three times as likely to develop personality disorders during adolescence. Now, maternal verbal abuse. This is not physical abuse. This is not sexual abuse. This is maternal verbal abuse. So, that's really powerful in terms of prevention, making sure that primary caregivers, and I'm not just going to say mom, primary caregivers are cognizant and not verbally abusive. So, they understand that the impact that they may have in the child's developing psyche and that internal critic that they may have. So, they did this study. You know, they said, well, that can't be true. It can't just be this. We don't want to just blame mom. And they controlled for sibling temperament, childhood, physical or sexual abuse, neglect, parental education, parental psychopathology, and co-occurring psychiatric disorders. And they still found that that association between the development of personality disorders during adolescence and maternal verbal abuse existed. High reactivity and emotional dysregulation, children who are more sensitive, people who are more sensitive are more prone to develop personality disorders. These behaviors, again, are designed to either protect and push away or to bring in someone that can support and protect them. So, look at the function of the behavior. Association with negative peers and lack of secure attachment figures also factors in a little bit. They're still not really sure where they came from, but we can look at correlations and recognize the impact that certain things have on child development. Personality disorders typically first manifest in adolescence. Now remember, adolescence is a big span from about 13 to about 24. So, you got a window in there. Adolescents are expected to engage in more independent emotional regulation and self-control strategies. So, during this period, deficits in their self-regulatory skills, deficits in their inability or deficits in their ability to self-soothe, become a lot more apparent. And you remember high school, you remember early college, I mean, that's also a time of emotional angst and trying to find your identity. There's just so much stuff on top of hormones that adolescents are going through that, you know, it's a challenge for anybody to be, you know, great at self-regulation. But those with greater problems with self-regulatory skills start to stand out a little bit more in adolescence. There's a high rate of concurrent comorbid psychiatric disorders and physical health problems in people with personality disorders. So, looking for that, we want to rule out any physiological causes of some of their symptoms. And we also want to pay attention to the fact that they may have borderline personality disorder or whatever, but they may also have an eating disorder and depression. You know, so we don't use the five-axis diagnosis anymore, but making sure to recognize that a lot of times there's multiple diagnoses and issues that we need to deal with. And just like depression, BPD requires five out of nine symptoms, which results in 126 different possible presentations. So, yeah, it's part art and part science to do diagnosis, especially once you start looking at differential diagnosis and is this better explained by. People with personality disorders may use drugs in a variety of ways and settings. At the beginning of a crisis episode, a client with a personality disorder might use in an attempt to quell the growing sense of tension or loss of control. So, they start trying to calm themselves down. Remember, they don't have good self-regulatory skills, so substances may be used to self-medicate. However, they often use substances in idiosyncratic and unpredictable patterns. So, when you might expect them to use something that would help calm them down, they might use a stimulant. When times when you wouldn't expect them to use, they may use just to get the rush, the excitement. The reason poly drug use and poly addiction, so addiction to gambling, addiction to sex, addiction to other things is also common. Individuals with personality disorders are very skilled at doctor shopping for medications that they favor, especially, you know, benzos and opiates. It's important to pay attention to that from a clinical standpoint if we see a client that is presenting on these medications to be cognizant that they may also be abusing other substances. Now, addictive disorders. We've looked at mood. We've looked at personality. Now we're moving on to addictions. Addictive disorders are strongly correlated with the presence of mood disorders. That chicken egg thing, like I said earlier, once you start flooding the brain with dopamine and, you know, whatever other neurotransmitters are being triggered with your particular addictive behavior, things start getting out of whack so people start experiencing more depression and anxiety. The development of mood disorders may begin because of these neurochemical effects. They can also begin because of the physical effects of the substance, leading to problems maintaining blood sugar, exhaustion, fatigue. It can also, using substances can have social and environmental effects, you know, family backing away, arguments, chaos, you know, tension within the family, which can prompt the development of anxiety and mood disorders. And employment and financial problems as the result of use can also trigger anxiety and depression. Addictive disorders are also strongly correlated with relapse or lack of treatment effectiveness for mood disorders. So if someone comes in with an addiction, but they're not presently symptomatic for a mood disorder, which is rare, but if it happens. It's more likely that that mood disorder, you'll have another episode. Most of the time, by the time people come to treatment for their addiction, they've already, their mood disorder has already relapsed. They've already started feeling depressed again and tried to self-medicate and it's just not working. So they're finally there to try the last thing that they can think of to make the pain stop, which is treatment. Risk factors for addictive disorders, genetics, childhood trauma, verbal abuse in general, high reactivity and emotional dysregulation. Again, people who are more sensitive tend to look for a way to kind of blunt the effect of all the stimulation from what's going on. Peers, lack of secure attachment figures and early use of substances. Remember from prior presentations, the earlier someone starts using substances or addictive behaviors including like online porn, the greater the damages or the greater the changes are in the brain of that person. So early use of substances actually has a lot more permanent effects than starting use later in life. So just reviewing real quickly criteria for substance use disorder and it is not abuse and dependence like it used to be in the DSM-4. It's substance use disorder. There is no differentiation. Larger amounts over a longer period of time, unsuccessful efforts to cut down. A great deal of time is spent getting, using or recovering from use and this can include recovering financially, craving or thinking about it constantly. It's not necessarily a physiological craving, but it can be a psychological craving. Recurrent use resulting in failure to fulfill major role obligations or in the case of something like porn or online gambling using at work. Continued use despite recurrent problems that are caused by or worsened by use. So you know this is causing problems, but you just can't give it up. Important activities are reduced because of use. Recurrent use and physically hazardous situations such as while driving or using substances so you're inebriated while you have young children in your care, things like that. Continued use despite knowing it's causing problems. Tolerance is the diminished effect. And you know with drugs, that's an easy one. You take a certain amount. It doesn't have the same effect. You take more of it in order to get that effect. Opiates are your, you know, primary, not primary, but best example of that. What the dose that works for the first two weeks is probably not going to work as well after that first two weeks and you'll need to eventually up the dose. Same thing with gambling, for example. Maybe you start out gambling and you're playing, you know, quarter slots and I know virtually nothing about gambling. But after a while playing quarter slots isn't going to do much and you're going to start playing $20 a hand poker or whatever it is in order to get that same feeling that same rush that same tension and release. And withdrawal, which can be psychological or physiological, where you're thinking about it constantly, where you're depressed, if you can't access it where you may have some anxiety, if you can't access whatever the substance or behavior is. The continuum of substance use disorders goes from initiation and intoxication. You use it, you get, you get drunk or you get elated. It's just like, wow, rush. That's awesome. A lot of people don't progress past that. Harmful use is when people start using it to cope and escape from life. And it starts causing problems in their life. Abuse is when they're using it more and more and it's causing more and more problems. Dependence, you have to have the tolerance and withdrawal. So you have to have somebody who's needed to increase the amount over time or combine it, for example. And the withdrawal, that sense of not being able to go on without it, that sense of something's wrong if you don't have it in your system. It's just like depression, anxiety that are associated with that. And with substances, there is, you know, there are physiological withdrawal symptoms. Some people get through withdrawal and move on. They kind of jump past craving and they move into recovery. They move into treatment. But for a lot of people, they go through withdrawal, then they start craving again and they relapse before they move into recovery. You don't necessarily relapse after you get into recovery, although it's definitely not uncommon. But a lot of people do relapse somewhere along the way before they finally say, all right, I'm sick and tired of being sick and tired and I need to go to treatment or I need to get this done if that means going to 12-step meetings or whatever it is. According to the gelatin curve, you know, basically addiction has a pretty predictable course, occasional use and involvement, followed by frequent use for relief or pleasure, increases in tolerance, superstitious use or involvement. So I have to have a drink in order to be able to function at this situation or, you know, convincing yourself different reasons why you have to engage in it. Increasing physical or psychological dependence, feelings of guilt about use and about what you're not doing because of your use, decreases of ability to stop when others do or would, promises to stop or change, fail. So, you know, people are starting to notice that there's a problem and you keep saying, yeah, yeah, I got it under control and then you're back at it again. Reduce self-esteem because, you know, you want to do the next right thing, but this addiction keeps calling you back. Avoid family and friends. Start developing unreasonable resentments, blaming people for everything they do, blaming them for not understanding whatever. Guilt and shame increase, job loss, neglect of health, physical deterioration, impaired thinking, increased mood and personality issues, and then ends with obsession with use and involvement. The person is just using as soon as they start to detox from it, they use again because their brain is and body are dependent on it at this point. And the rest of their life is pretty much a shamble, so they don't want to pull their head out of the ground and look around at what's going on because that's just too much to handle. Recovery, again, follows a very similar pattern, honest desire for help, hope that recovery is possible. No wrong door means that wherever they enter the system, we can provide hope. If it's at the doctor's office, the doctor can do a brief intervention and get them referred for treatment. If they present at a counselor's office, we can do an assessment and refer them for medical treatment as needed and wrap around services. If they present at their case worker for social services office, they will get assessed and people will be able to lay out for them the resources that are available. So they can see that recovery is possible and the resources are there. They begin proper self-care, start appreciating the possibilities, what recovery could look like, what life could be like, start getting social support, takes that personal inventory to decide what's important and where do I need to go from here, what's the next step to improve the next moment. Develops alternate distress tolerance and coping skills for current triggers, so we need to be able to deal with not only the cravings and the withdrawal and all that, but life. Begin setting smart goals and achieving them, which leads to increases in self-esteem and increases in emotional and behavioral control. Through all of this, the desire to escape starts to go away and they start going, you know, this whole recovery lifestyle, there's something to it, I'm liking it. And employment and finances start to stabilize. So it follows a very similar course to mental health recovery, which is awesome because since most people with addictions have mental health issues and it's not uncommon for people with mental health issues to have addictions, since the course is very similar, we can provide concurrent treatment, you know, when we're teaching about setting smart goals, when we're teaching about distress tolerance and coping skills, when we're helping them create a vision of what recovery looks like. These are all things that are common to all types of recovery. Crosscutting issues, suicidality, abuse and misuse of alcohol or drugs is a major risk factor in suicide. Alcohol abuse is associated with 25 to 50% of suicides. So if we have a client who is seeing us for depression and we know that they're drinking, especially if they're drinking heavily, not necessarily an alcoholic, not necessarily abuse, but they're drinking a lot. They're, you know, self-medicating a little bit, even worse, they're drinking and taking antidepressants. We need to be very cognizant of the fact that they're at a much greater suicide risk. There's a particularly strong relationship between substance abuse and suicide among young people. So, you know, it's not uncommon for youth to drink at parties and things, but if we do hear about them using substances, you know, your patient divulges that to you. We need to be aware that they, again, are at an increased risk of suicide, especially if they have access to substances, you know, at home when mom and dad aren't there or whatever, when they might be more prone to commit suicide, which they probably are less, a lot less likely to do at a party or something. Comorbidity of a substance use disorder and depression increases suicide risk. So if they're already abusing substances to the point where they qualify for a substance use disorder and they have meet the criteria for depression or even persistent depressive disorder, they have an increased suicide risk. So paying attention and it's not just alcohol, it's any substance. If they're using it in a way that's monkeying with their neurotransmitters, it increases their risk of suicide. Nicotine dependence is the other cross-cutting issue because people who are, who have mental health issues but no other addictions may be addicted to nicotine. And people who have addictions often are addicted to nicotine. There are six FDA approved treatments for tobacco dependence, bupropion, and then five different nicotine replacement treatments. They found these to be quite effective. Nicotine treatment medications are effective even without counseling, but adding psychosocial treatments enhances outcomes by at least 50%. So even if somebody is not willing to do the tobacco cessation program or whatever, they can still go to their doctor, get on medication for it, and have a good chance of being able to stop smoking or dipping or whatever it is. Specific coping skills should be addressed to help smokers cope with cravings associated with smoking cues. And smoking cues, like we've talked about before, can be time of day. It can be a place. It can be a person. It can be a smell. So we need to help them develop distress tolerance skills. For a lot of smokers, too, is not having anything to do with their hands. They're so used to having a cigarette in their hands. So if they can find something to do, whether it's playing a game of some sort on their mobile device or crocheting or writing or something to keep their hands busy will help. I know a lot of people will turn to eating and it does keep your hands busy, but then you have the other problems of additional weight gain and things. When clients with serious mental illnesses attempt to quit smoking, and this is major depressive disorder, the whole gamut, a diagnosable mental illness, not just schizophrenia or something. We want to watch for changes in mental status and exacerbation of mood disorders. Is their depression getting worse? Is their anxiety getting worse? And I tend to tell patients ahead of time that this may happen. And if it does, let me know. Let your doctor know. And we can help you through it. We want to look for medication side effects and interactions. If they're taking any of the nicotine replacement treatments or bupropion, there are side effects which may be unpleasant and maybe unacceptable, which unacceptable side effects are those side effects that would make a person discontinue treatment or be non-compliant. We also want to look for medication interactions. If they're taking these medications, it may interact with other medications or herbs that they take and cause mood symptoms, increases in anxiety, racing heart, things like that. And there's also potentially a need to lower some psychiatric medication dosages due to the tobacco smoke interaction. When the person's not smoking anymore, they may not need as much of the medication. So most of the psychiatrists should be aware of this, but we do want to make sure that clients can advocate for themselves. Addictions and mental health issues follow a similar course. Recovery requires the desire to change and hope that change will occur. Remembering that people may go through multiple episodes. And what we want to look at for each person is what's different when you're not symptomatic and how can we enhance that. And leading up to each episode, what triggers it? And look broadly, not just at what mood things or what stressors were there, but were you taking care of yourself? Were you exercising? Was it a seasonal change? So there wasn't as much sunlight. Did you change jobs? What happened? Mental health clinicians need to be alert to misuse of substances or problematic engagement in addictive type behaviors such as online gambling or Internet porn and exacerbation of mood disorders due to use or withdrawal, even during treatment. So if someone, you know, maybe they have been using alcohol kind of heavily, but they're don't qualify for a substance use disorder, but they decide to quit drinking. They may have an increase, a substantial increase in anxiety. If they've been drinking a lot where they've developed a tolerance, detox from benzodiazepines and alcohol can both be life threatening. So we want to make sure that people realize, you know, if they're actually alcoholic, they've been drinking that much where they've developed alcohol dependence. They need to be medically supervised during withdrawal. But for the rest of the people that are just drinking kind of heavily, helping them realize that their mood issues may get worse before they get better while their neurotransmitters stabilize. Addiction clinicians need to be alert to changes in mental health. If people start developing mood symptoms or mental health symptoms, we need to be able to either treat them or refer and the potential for addiction relapse with mental health relapse. So if we've got a client and they went through addiction treatment and they're doing grand and they're in good solid recovery, but then they have an episode of major depressive disorder. They are at a much greater risk for relapse of their addiction. So we need to put in some really strong relapse prevention skills and support. Are there any questions? Okay. Well, I will see you tomorrow. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allCEUs.com slash counselor toolbox. This episode has been brought to you in part by allCEUs.com, providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists, and nurses since 2006. Use coupon code, counselor toolbox to get a 20% discount off your order this month.