1. HIV: Beyond 101 Co-occurring Disorders: The Collision of Mental Health, Substance Abuse and HIV/AIDS Henry van Oudheusden MA,MSW Pres/CEO Behavioral Health Services Inc.

2. We do a tremendous disservice when we speak of co-occurring disordered individuals as though they were one homogenous group with identical lives, symptoms and treatment needs Labeling individuals as “Dually Diagnosed” or “Co- occurring Disordered” is clinically as gross and unhelpful as labeling someone as an addicts or crazy. People are Persons….. Clearer identification of persons with multiple disorders is essential to the creation of a helpful recovery plan and insuring positive and life giving outcomes.

3. Defining Co-occurring DSM IV R Disorders Classic: Primary Clinical Axis I Mental Health Disorder (ONSET BETWEEN 1.5-EARLY TEENS) as well as an unrelated Primary Clinical Axis I (ONSET ABUSE 10-11 AND DEPENDENCE MID TEENS) Substance Use Disorder. Less Classic: Same as above but it doesn’t matter if one was ‘induced’ by the other, if they now co-exist independently or dependently and are each in need of clinical concern or treatment. For under 18 y/o: What is use? Is any use abuse? How do we frame abuse and dependence in teen environment?

4. Not All Co-occurring Disordered Persons are Alike: A COD Matrix High Psychological (Psychotic or when High Substance Abuse (abuse/dependence) the disorder is deemed severe) High Substance (abuse/dependence) Low Psychological (Disorder does not cause major lack of functioning in life domains) I II Schizophrenic +Meth dependent Meth Dependent and Oppositional Defiant Conduct Disorder +Alcohol dependent Marijuana dependent and Adjustment Disorder High Psychological Low Substance Low Substance Low Psychological III IV schizo--effective and 1x wk MJ use Attention-Deficit/Hyperactivity Disorder-NOS Bi-Polar I and ‘occasional-non patterned Alcohol use weekend with friends MJ use Mental Health=System that deals with Psychological Disorders Substance Abuse=System that deals with Substance Use Disorders Medical= System that deals with physical disorders Often specialists in one system do not have a knowledge set in the other.

5. The Culture of Persons with HIV/AIDS & Co- occurring disorders may Include: Co-occurring WORLD Immediate Family Work-SSI School Housing/Neighborhood Environment Parole Probation Peers Social Life Substance use Extended Family Mental/emotional issues Self identity Esteem-Biology stress

6. Progression of Mood Altering Substance Use 1980 & 2006 Fetal Alcohol Spectrum Disorder---Substance use in-uterus No Social (Isolated Use Experimentation Use Use) Abuse Dependence ------------ ------------------------- ------------------------------------------------------------- 0-2 3-5 6-8 9-10 11-12 13-14 15-16 17 18 20 22 14 y/o-abuse 15.5 y/o dependence Anxiety disorders 3.8 onset SEXUAL ACTIVITY Attention Deficit Disorders-1.3-2.4 HIV/AIDS-onset Oppositional Defiant-5 Conduct Disorder-5.6 Schizophrenia-effective disorders Teen years and mid-thirties Use: Most commonly used drug age 12+ in Feb-07 report: MJ/Prescription, Alcohol, and Meth. Abuse: DMS IV Dependence: DSM IV “Onset in the late 20’s 30’s and 40’s”

7. The Prefrontal Cortex, the part of the brain that controls our executive functioning, is not fully developed in children/youth and undergoes major growth, development and maturation between the ages 17-20. Long term and short term consequences to actions are lodged here. Any substance use prior to age 16-17 interferes with this portion of the brain’s normal development.

8. Drug addiction is a brain disease that affects behavior. Brain changes in addiction help explain continued drug abuse and relapse.

9. All substance alter a person’s mood and affects brain functioning Uppers- Stimulants: Cocaine Meth Crack Crank Downers-Depressants: Alcohol Marijuana Heroine Pain Prescription meds Dissociative: PCP Hallucinogens Ecstasy

10. IS IT: Major Depressive Episode 1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. 2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) 3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. 4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self ‑ reproach or guilt about being sick) 8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

11. OR IS IT: Alcohol Usage Is the only drug that is cellular Has predictable pathway for all humans but works faster in women, children and youth as depressant Is the leading cause or exacerbation of other biological illnesses. “Makes” people depressed

12. Complex Intertwine of Mental Health and Substance Use Self medication against the negative symptoms of mental health and or the negative effects of psychotropic medications. Self medication from socio-economic ills Inability or giving up the struggle that may come with living with HIV/AIDS

13. HIV/AIDS H – HUMAN I – IMMUNO-DEFICIENCY V – VIRUS A – ACQUIRED I – IMMUNE- D - DEFICIENCY S – SYNDROME The most important word here is Acquired. HIV infection is not inherited. It’s not genetic and almost all cases of HIV can be prevented.

14. ‘Normal’ individuals struggle with moods and the challenges of life on its own terms. Persons with a substance use disorder X 1 Persons with a mental health disorder X 1 Persons with Co-occurring Disorders ____  X 2 Substance Dependence, Mental Illness and HIV/AIDS are chronic relapsing Disorders. Respect, engagement, patience with understanding, multiple treatments, strong therapeutic alliances are ESSENTIAL.

15. Continuum of Care for Persons with Co-occurring Disorders DETOX/Stabilization LONG TERM OUT PATIENT RESIDENTIAL SHORT TERM INTENSIVE AFTERCARE RESIDENTIAL OUTPATIENT

16. Each Co-occurring Disordered Person with HIV/AIDS is a story Listen with care Respond with empathy Watch and anticipate with Understanding Leave all judgment at home Know your resources