Dr. Dawn-Elise Snipes is the Executive Director of AllCEUs.com Counselor Continuing Education, and host of Counselor Toolbox Podcast, Case Management Toolbox Podcast, NCMHCE Exam Review Podcase, Addiction Counselor Exam Review Podcast and Happiness Isn't Brain Surgery Podcast.
ADHD, Addiction and Mental Health Dr. Dawn-Elise Snipes This is part 1 or 2 part series. See next part's notes for CEUs Objectives ~ Explore the connections and symptom overlaps between ADHD, addiction and mental illnesses ~ Explore the impact of these symptoms on the individual. Intro ~ ADHD is one of the most common psychiatric disorders, with a worldwide prevalence of 5.2 % among children and adolescents, persisting into adulthood in 60–70 % of cases either as a residual or as a full clinical disorder ~ Medications used to treat ADHD such as methylphenidate, amphetamine, and atomoxetine indicate a dopamine/norepinephrine dysfunction as the neurochemical basis of ADHD and a potential target for anxiety and depression ~ The presence of probable ADHD and the severity of ADHD symptoms are related with the severity of insomnia, even after controlling the depression, anxiety Attention Deficit/Hyperactivity ~ Difficulty getting organized ~ Chronic procrastination or trouble getting started ~ Many projects going simultaneously ~ Trouble with follow-through ~ A tendency to say whatever comes to mind without considering timing or appropriateness ~ A frequent search for high stimulation ~ An intolerance of boredom ~ Easy distractibility; trouble focusing attention, tendency to tune out or drift away in the middle of a page or conversation ~ Trouble following “proper” procedures ~ Impatient; low tolerance of frustration (Emotional Dysregulation) ~ Impulsive, either verbally or in action (e.g., impulsive spending of money) ~ A sense of insecurity ~ Mood swings, especially when disengaged from a person or a project ~ Physical or cognitive restlessness ~ Chronic problems with self-esteem ~ Inaccurate self-observation ~ Involvement in goal directed activities Adult ADHD and Comorbidities ~ ADHD and mood disorders have similar ~ neurobiological differences in the prefrontal cortex, which is responsible for attention, behaviour selection, and emotion. ~ abnormalities in dopamine (DA) and norepinephrine (NE) signaling ~ The National Comorbidity Survey reported that adults with ADHD are 3x more likely to develop major depressive disorder (MDD), 6x more likely to develop persistent depressive disorder. ~ Rates of ADHD in people with bipolar disorder are between 9.5% and 21.2%, and rates of bipolar disorder in people with ADHD are 5.1% and 47.1% ~ Characteristics of the manic or elevated phase of bipolar disorder that overlap with ADHD include restlessness, talkativeness, distractibility, and fidgeting Adult ADHD and Comorbidities ~ Prevalence rates of depression in individuals with ADHD are 18.6% to 53.3%. And comorbid ADHD in individuals with depression at rates of 9% to 16% ~ Factors that were significantly predictive of undetected ADHD included the number of SSRIs previously tried that failed to attenuate symptoms. (Serotonergic agents alone would not be expected to improve ADHD symptoms, which typically respond to noradrenalin-dopamine reuptake inhibitors) ~ Rates of anxiety disorders in individuals with ADHD approach 50% ~ Anxiety disorders and ADHD have similar neurobiological deficits in the prefrontal cortex related to “cool” processing and deficits in top-down regulation. Adult ADHD and Comorbidities ~ Addiction is approximately twice as common in individuals with ADHD ~ The association between ADHD and SUD is bidirectional since individuals with ADHD more frequently report the use of substances in order to manage their mood or as sleep aids ~ Individuals with ADHD also experience neuropsychological difficulties associated with ~ Inhibition ~ Memory ~ Executive functioning / organization ~ Decision making ~ Emotional dysregulation / self regulation ~ Time management ADHD and Trauma Impact of Adult ADHD and Comorbidities ~ Adult ADHD has been associated with ~ Poorer driving and a higher incidence of traffic citations and motor vehicle accidents. ~ Negative consequences for individuals’ self-esteem ~ Difficulty in interpersonal relationships ~ Underemployment: Adults with ADHD were 42% less likely to be employed full-time as were adults without ADHD ~ Early and optimal treatment of ADHD could potentially prevent the later development of psychiatric comorbidities Adult ADHD Key Questions ~ 3 key questions that clinicians can ask to screen for undiagnosed ADHD in complicated patients: ~ Have you had consistent problems with attention and distractibility most of your life? ~ Have your current complaints (i.e. difficulty in relationships, emotional dysregulation) been present over the last 10 or 20 years? ~ What were you like in the classroom as a child? Summary ~ ADHD and many disorders have similar symptoms and common neurological and neurochemical causes including dysfunction in the frontal cortex and the dopamine and norepinephrine symptoms. ~ Treatment strategies should ~ Address behavioral manifestations to improve self esteem, work/school functioning and interpersonal skills ~ Explore the root causes of the symptoms to ensure adequate differential diagnosis / comorbid diagnosis of mental health issues including trauma, depression and bipolar disorder. ~ Part 2 of this presentation will cover cognitive, behavioral and environmental interventions
Neurobiology of Obsessive Compulsive Disorder and Co-Occurring Mental Health Issues Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LCSW AllCEUs Counselor Continuing Education CEUs available at https://allceus.com/member/cart/index/product/id/1353/c/ #ocdawareness #obsessivecompulsivedisorder Objectives – Explore the overlap and concurrence of OCD, and generalized anxiety, eating disorders, addiction, PTSD, body dysmorphic disorder – Identify neurotransmitters, emotional reactions and cognitive issues involved in each and what that may mean for treatment Introduction – ~90% of individuals with OCD have other psychiatric comorbidities – Anxiety disorders 75.8% – Mood disorders 63.3% – Major depressive disorder (MDD) 40.7% – Eating Disorders 8-12% – BDD in patients with OCD is 9% to 15% (compared to 3% in non-OCD) – Impulse control disorders 55.9% – Substance use disorders (SUDs) 38.6% – Due to the differences in neurological and neurochemical profiles of the different disorders, it is important to recognize that treatments need to differ. Intro – What is OCD – Obsessions are anxiety-based thoughts – Anxiety is a reaction to a perceived threat – Compulsions are designed to reduce the anxiety and protect from the perceived threat – Part of treatment for OCD is addressing the events and related cognitions that spawn the anxiety-provoking thoughts – What happened that started making you feel anxious about germs/fire/burglars/harm coming to others / harming others – What messages did you get that told you that you were “going to Hell” (resulting in compulsive behaviors to prevent going to Hell when you have those thoughts) Neurology of OCD and Other Disorders – Frontal Cortex – Addiction, OCD, PTSD, Bulimia and Anorexia are all associated with alterations in the frontal cortex. – HPA Axis Dysregulation – HPA-Axis dysregulation is associated with addiction, OCD, PTSD,depression, bulimia and anorexia – Persistent stressful events or traumatic events can lead to changes in the HPA-Axis (hypocortisolism) which cause hyperactivation of the HPA-Axis in times of stress (Flat or furious) and alterations in cortisol, glutamate, norepinephrine, serotonin, dopamine, oxytocin, DHEA and gonadal hormones. Neurology of OCD and Other Disorders – HPA Axis Dysregulation – Interventions – Address trauma related stimuli to increase safety and empowerment – Develop emotional regulation skills to reduce the magnitude of HPA-Axis activation – Improve health behaviors to reduce biological stressors (exhaustion, malnutrition, inflammation) – Address addictive behaviors which directly or indirectly activate the stress response Neurology of OCD and Other Disorders – Dopamine (Goal-directed behaviors) – Low dopamine is associated with depression, bulimia – High dopamine associated with anxiety disorders, OCD, PTSD, anorexia – Interventions: – Address the function and cause of the goal directed behavior – Augmentation of SSRIs with atypical antipsychotics – Norepinephrine (emotional memory) – Low norepinephrine is associated with depression – High norepinephrine is associated with anxiety, OCD, PTSD and HPA-Axis activation Neurology of OCD – Glutamate & GABA – A disruption in the balance between glutamate and GABA neurotransmission within the frontal cortex contribute to OCD – Low levels of GABA are seen in people with depression – High levels of glutamate are associated with HPA-Axis dysregulation, anxiety disorders – Interventions: HPA-Axis Regulation Neurology of OCD – Serotonin – Low serotonin (5-HT1A and 5-HT2A ) are associated with bulimia, OCD, addiction, anxiety, depression – High serotonin (5-HT2C ) is associated with addiction (suppresses dopamine) – Interventions – Nutrition – Sunlight / Vitamin D / Circadian Rhythms – Exercise – HPA-Axis Regulation Neurology of OCD – Cortisol – Much higher in male and female patients with OCD – A blunted cortisol response was associated with obsessions in women – A more flattened diurnal cortisol slope was associated with compulsive symptoms (ordering) in men. – Interventions – Circadian rhythm regulation – HPA-Axis regulation Neurology of OCD – DHEA (converted into testosterone and estrogen) – Estrogen and progesterone have been shown to modulate serotonin, dopamine, and glutamate levels all of which have been shown to be dysregulated in OCD patients – DHEA and cortisol levels have been found to be higher in patients with anxiety disorders such as panic disorder, OCD, PTSD, depression, and eating disorders possibly due to HPA Axis dysregulation Neurology of OCD – Gonadal Hormones – Alterations in gonadal hormones and the HPG axis are implicated in anxiety disorders, PTSD, OCD and depression – Estrogen & Progesterone – Progesterone metabolites (pregnanolone and allopregnanolone) show antianxiety properties by increasing GABA-A – Low estrogen & progesterone reduce serotonin signaling and are associated with OCD – Testosterone – Much lower in male patients only implicating the HPG-Axis – Interventions – Medical evaluation for gonadal hormone levels, DHEA and Oxytocin Neurology of OCD – Oxytocin – Oxytocin is produced in the hypothalamus and modulates the HPA-Axis but taken orally or IV cannot cross the BBB – Reduced OT as a result of disrupted attachment (child or adult) appears to impact the regulation of the HPA-Axis – Interventions – Intranasal OT – Improved attachment relationships – Oxytocin stimulating activities (ESAs) – Treatment with SSRIs (paroxetine) modulated oxytocin levels which are thought to modulate the stress response (HPA-Axis) and improve OCD, depression, anxiety , PTSD symptoms Summary – There is significant overlap between OCD and other psychiatric disorders – While ERP and SSRIs are the gold standard for addressing OCD behaviors, it is also important to address other underlying issues which may contribute to neurotransmitter disruption. – Trauma history (powerlessness and unsafeness) – Lack of emotional regulation skills – Lack of happiness promoting behaviors – Lack of secure attachment (oxytocin) – Poor nutrition, sleep, iron deficiency – Hormone imbalances (gonadal or thyroid) – Medication side effects (hormones, steroids, thyroid, RLS, antipsychotics)
Obsessive Compulsive Disorder and Addiction Awareness #ocdawareness #obsessivecompulsivedisorder Cheap CEUs are available for this presentation at https://www.allceus.com/member/cart/index/product/id/1352/c/ Objectives ~ Define obsessions and compulsions ~ Define obsessive compulsive personality disorder ~ Define addiction ~ Explore common obsessions and compulsions and their function ~ Explore why addiction often co-occurs with OCD ~ Identify interventions appropriate to assist people with OCD, OCPD and Addiction. Introduction ~ “Obsessive-compulsive disorder (OCD), impulse control disorders (ICD) and substance-related disorders (SUD) overlap on different levels, including phenomenology, co-morbidity, neurocircuitry, neurocognition, neurochemistry and family history” Obsessive-Compulsive Disorder, Impulse Control Disorders and Drug Addiction ~ Activity in the orbitofrontal cortex is associated with cocaine and alcohol craving and obsessive–compulsive disorder ~ Obsessions and compulsions are central characteristics of OCD and addiction ~ Proposed that impulse control and obsessive- compulsive disorders may acquire qualities of the other with time Introduction ~ Compulsivity in OCD and addictions is related to impaired dopamine and serotonin release ~ Treatment of these disorders must address alterations in the underlying motivations (experiential learning) and neurobiology Obsessions ~ Obsession ~ Disturbing recurrent and persistent thoughts (if I don’t…) or impulses (I must…) that are intrusive ~ Fears of germs, taboo thoughts, aggressive thoughts, need to do particular behaviors to prevent harm ~ Thoughts do not focus exclusively on real problems (generalized anxiety, eating disorders, addiction, PTSD, postpartum depression) ~ The person attempts to ignore or suppress the thoughts or impulses ~ The person is aware that the obsessional thoughts, impulses, or images are a product of his or her own mind Common Obsessions ~ Relationship ~ “If I enjoy when my partner is away, maybe I don't really love them.” ~ “Sometimes I look at other people and think about cheating. Maybe I secretly want someone else.“ ~ “Sometimes my partner looks at other people. Maybe they want someone else.” ~ “My partner hasn’t texted me all day. They must be cheating on me or not want me anymore.” ~ Harm OCD ~ “If I drive on a bridge I might drive off and kill everyone” ~ “If the doors aren’t locked someone will break in and kill us.” ~ If I didn’t turn off the stove… ~ If I am around other people… Common Obsessions ~ Health ~ What if this pain is cancer? Compulsions ~ Repetitive behaviors or thoughts that the person feels driven to perform to prevent or reduce distress or keep something bad form happening ~ The symptoms of OCD are not the result of another psychiatric disorder present or caused by a medical condition or substance abuse (i.e. cravings, diabetes, Chron’s disease). Common Compulsions ~ Relationship ~ Comparing partner to others ~ Comparing self to others ~ Frequent breakups ~ Needing frequent reassurance ~ Harm ~ Checking ~ Washing ~ Isolating ~ Prayer ~ Health ~ Nutrition ~ Detoxification (Exercise, diet, sauna) ~ General ~ Magical thinking (rituals, mantras) Obsessive Compulsive Personality Disorder ~ A pervasive pattern of preoccupation with orderliness, perfectionism, and control in a variety of contexts beginning by early adulthood as indicated by 4+ of the following: ~ Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. ~ Shows perfectionism that interferes with task completion ~ Is excessively and unnecessarily devoted to productivity to the exclusion of recreation ~ Is overconscientious and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). ~ Is unable to discard worn-out or worthless objects even when they have no sentimental value. (Hoarding) ~ Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. ~ Adopts a miserly spending style ~ Shows rigidity and stubbornness Interventions ~ Medications for addiction which modulate dopamine system through ~ Opioid (e.g. Buprenorphine and naltrexone) ~ Glutamate (e.g. Topiramate) ~ Serotonin/ 5HT3 (e.g. Ondansetron) ~ GABA (e.g. baclofen and topiramate) ~ Treatment of these disorders must account for alterations in the underlying neurobiology of the condition. For example ~ Naltrexone for people with co-morbid SUD and ICD ~ Topiramate for people with co-morbid ICD and eating disorders Interventions–Cognitive ~ Explore when the OCD or OCPD began ~ Explore when the addiction began ~ In what ways does the OCD or OCPD ~ Address feelings of unsafeness? ~ Develop a checklist ~ Journaling and exploring probability that something bad will happen ~ Reaching out to a support person (i.e. feel overpowered by emotions or thoughts) ~ Protect from rejection or failure? ~ Explore the beliefs surrounding rejection and failure ~ Enhance hardiness ~ Improve self-esteem ~ Explore where those messages came from and their validity Interventions–Cognitive ~ How does the addiction help the person? ~ Use chaining to explore how the addiction relates to the obsessive thoughts to trigger cravings and compulsions (using) ~ Fears of germs anxiety  cravings to rebalance neurotransmitters  use ~ Discussion: What is your thought/or the situation  what are your feelings  what are your urges and what is the function of those urges ~ Learn about distress intolerant thoughts (Draw from the hat) ~ Develop alternative self statements ~ Learn about urges and riding the wave ~ Learn about unhooking ~ Develop distress tolerance skills Interventions ~ Identify and develop a plan to mitigate triggers or vulnerabilities for the OCD or OCPD (logs, plans) ~ Beach Ball Activity: Common triggers for OCs / OCPD behavior intensification ~ Address cognitive distortions that contribute to distress ~ Mindreading, personalization, all or nothing, catastrophizing, availability heuristic (likelihood) ~ Facts, exceptions, probability ~ Mindful awareness activities to improve self-awareness of increasing anxiety or anger levels and promote early intervention ~ Psychological flexibility ~ 4 Stations: For and against behaviors and thoughts Interventions ~ Exposure and Response Prevention (ERP w/biofeedback) ~ Think the thought or about the situation describe how you feel in session ~ If I don’t clean the kitchen, my husband will die. ~ If I am around people I will get sick and die. ~ Practice re-regulation/distress tolerance activities when prevented from engaging in the compulsive behavior (breathing, talking to a support) Summary ~ There is significant overlap between OCD and addictive behaviors. ~ Treatment involves ~ Identifying the underlying thoughts ~ Exploring what is contributing to fears of unsafeness (harm, rejection) and powerlessness ~ Identifying the function of the thoughts and behaviors ~ Practice Exposure and Response Prevention to decondition the compulsive behaviors ~ Potentially medicating the neurotransmitter imbalance until the brain can adapt (reroute)
Many Forms of Depression & 25 Tips for Recovery Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC AllCEUs Counselor Continuing Education Symptoms of the Flu – Fever or feeling feverish/chills, sweats – Cough, chest discomfort – Sore throat – Runny or stuffy nose, sinus congestion – Muscle or body aches – Headaches – Exhaustion – Vomiting and diarrhea Types – Major Depressive Disorder (including w/psychotic features) – Persistent Depressive Disorder (High Functioning Depression) – Postpartum Depression – Premenstrual Dysphoric Disorder – Depression in Early Recovery From Addiction – Bipolar Depression – Seasonal Affective Disorder – Grief – Situational Depression (not including grief) – Depression due to a general medical condition (autoimmune issues, stroke, heart disease, dementia…) PACER Effects – Depression can: – Physical Health – Alter sleep → Causing changes in circadian rhythms which further alter the balance and timing of neurotransmitter release. – Alter appetite → poor nutrition – Increase consumption of stimulants to cope with fatigue – Cause fatigue, lethargy – Interfere with ability to work – Interfere with activities of daily living PACER Effects – Depression can impact: – Affect – Increase feelings of guilt and worthlessness, compounding the depression – Lack of interest in things you used to enjoy – Cognition – Make concentration difficult – Alter self esteem due to internal (and external) criticism – Increase attention to negative stimuli and thoughts – Self harm or suicidal thoughts – Environment – Staying inside (often in the dark and/or in bed) – Disorganization PACER Effects – Depression can impact: – Relationships – Attachment difficulties – Consistency: Withdrawal – Responsiveness: Inability to be emotionally available – Attention – Validation: – Empathy: Irritability – Support PACER Interventions – Physical – Hydrate – Good nutrition – Breathe – Move – Rebalance circadian rhythms: Maintain a schedule, light therapy, sleep hygiene – Rule out or address thyroid or gonadal hormone imbalances, vitamin deficiencies, autoimmune and cardiovascular issues – Pace yourself PACER Interventions – Affective – Add in the happy for 10 minutes 2x per day – Develop distress tolerance skills: CATS – Comparisons – Activities – Thoughts – Sensations PACER Interventions – Cognitive – Identify and address core beliefs that are contributing to you feeling hopeless, helpless, and unsafe – Use reasoning that is focused on facts and probability – Focus on the positive for 20 minutes a day – Practice mindfulness to tame “monkey mind” – Identify what parts of the situation are within your control – When you are having a bad moment, accept it nonjudgmentally, explore the reason and ask yourself “What can I do to improve the next moment?” PACER Interventions – Environmental – Make it bright during the day and dark at night – Get dressed – Get out of the bedroom (preferably the house) – Essential Oils – Linalool: Lavender, Cinnamon, Basil – Geraniol: Citronella, geranium, rose oil, rose geranium – Limonene: Citrus fruits (d-limonene cleaner), bergamot – Others: Peppermint, rosemary, pine, clary sage – *bolded oils also help with inflammation PACER Interventions – Relational – Help loved ones understand what is going on and how they can help and encourage you – Don’t ASSume you “know” how others are thinking or feeling about you – Get Support – Ask yourself what you would do for someone else who was having this problem. – THINK before you speak – True – Helpful – Inspiring – Necessary – Kind – Contribute
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