1. OBJECTIVE To learn to identify and assess patients/clients/consumers suffering from concurrent disorders.

2. ECA: DUAL DIAGNOSIS 29% with psychiatric illness have had a substance abuse d/o. 37% of alcoholics have a mental illness other than a substance abuse d/o 53% with drug abuse or dependence have at least one other psychiatric dlo 64% of drug abusers in treatment have a mental d/o.

3. DEFINITION OF MENTAL DISORDER “A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.”

4. MENTAL ILLNESSES Anxiety Disorders Mood Disorders Posttraumatic Stress Disorder ADHD Eating Disorders Psychotic Disorders

5. ANXIETY DISORDERS Generalized: anxiety is unvarying and persistent. Phobic: anxiety is intermittent and arises in particular circumstances. Panic: anxiety is intermittent and unrelated to particular circumstances. OCD: obsessional thinking, compulsive behaviour.

6. ANXIETY DISORDER Qs Have you ever had a panic attack, when you suddenly felt frightened or anxious or suddenly developed a lot of physical symptoms? In the last six months, have you been particularly nervous or anxious? Do you worry a lot about bad things that might happen?

7. MOOD DISORDERS Depressive: depressed mood, loss of interest. Mania: elated mood, irritable Dysthymia: long-term mild depression. Hypomania: elated, irritable, but functioning.

8. MOOD DISORDER Qs In the last month, has there been a period of time when you were feeling depressed or down most of the day nearly every day? (What was that like?) What about losing interest or pleasure in things you usually enjoyed?

9. PTSD History of trauma. Flashbacks, intrusive memories. Hypervigilance, disturbed sleep. Avoidance of reminders.

10. PTSD Most mental disorders improve with abstinence. PTSD is often an exception. Venlafaxine and the SSRIs are likely useful. Generally, substance use should be under good control and not likely to be triggered before imaginal or literal exposure to traumatic cues.

11. PTSD Q Sometimes things happen to people that are extremely upsetting – things like being in a life threatening situation like a major disaster, very serious accident or fire; being physically assaulted or raped; seeing another person killed or dead, or badly hurt, or hearing about something horrible that has happened to someone you are close to. At any time during your life, have any of these kinds of things happened to you?

12. AD/HD We have known for a long time that children with AD/HD are likely to have or develop substance dependence. Restlessness, fidgeting, variable attentiveness make AD/HD part of the differential diagnosis. The Wender Utah Rating Scale (WURS) is a useful screening instrument. Onset in childhood.

13. EATING DISORDERS Anorexia: underweight, loss of periods. Bulimia: binges, vomiting. All: distorted body image.

14. EATING DISORDER Qs Have you ever had a time when you weighed much less than other people thought you ought to weigh? Have you often had times when your eating was out of control? Tell me about those times.

15. PSYCHOTIC DISORDERS Delusions: incredible beliefs. Hallucinations: hearing, seeing, smelling what is not there (when fully awake). Loss of reality testing.

16. PSYCHOTIC SYMPTOM Qs Now I am going to ask you about unusual experiences that people sometimes have. Has it ever seemed like people were talking about you or taking special notice of you? Did you ever hear things that other people couldn’t hear, such as noises, or the voices of people whispering or talking? (Were you awake at the time?)

17. PERSONALITY DISORDERS “The difficult patient”. Antisocial PD Narcissistic PD Borderline PD

18. HOW IS PERSONALITY DISORDERED? Personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress. Personality traits: enduring patterns of perceiving, relating to, and thinking about the environment and oneself.