Mental Health and Wellness - Western State Hospital Internship Program

November 11 2016

Friday Factoids Catch-Up: Heroin and Fentanyl–A Match Made in Hell

Heroin use has always been a serious issue where drug abuse is concerned, but in the last few years it has become even more deadly due to fentanyl being added to give it more “kick”. Dealers have begun including fentanyl to improve the potency of their product; however, the equipment they use to measure out amounts for trafficking don’t usually measure at levels fine enough to ensure that the amount of fentanyl that has been added stays below overdose levels. To add to the danger, fentanyl sold at the street level is usually manufactured in “underground” labs which produce a far less pure product than pharmaceutical-grade labs, which can cause unpredictable effects on the body (Bond, 2016).

Heroin is classified by the DEA (Drug Enforcement Agency) as a Schedule I drug, while fentanyl is classified as a Schedule II drug. Both are opioid derivatives; however, while heroin is synthesized directly from morphine, fentanyl is a synthetic opioid analgesic, with a potency of 50x to 100x that of morphine (NIDA, 1969, 2011, 2014). While both have a high potential for abuse, there is a wide gulf between the two drugs with regard to the amount required to induce an overdose. An average sized adult male would take around 30g of heroin to produce an overdose situation, roughly an amount similar to 7 packets of sugar. By contrast, it would only take around 3g of fentanyl (little more than a ½ packet) to produce an overdose (Bond, 2016).

Fentanyl-laced heroin quickly reached crisis levels as it began to gain popularity among users. In March of 2015, the (DEA) issued a nationwide alert in response to a surge in overdose deaths from heroin laced with fentanyl (19 March 2015). While heroin has been recognized as having a high potential for abuse since the mid-1900s, fentanyl wasn’t added as a Schedule II substance until 2015, after recognizing that a variant, acetyl fentanyl, was being manufactured by Mexican cartels and smuggled stateside for distribution (10 September 2015). The problem has surged so much that “the National Forensic Laboratory Information System, which collects data from state and local police labs, reported 3,344 fentanyl submissions in 2014, up from 942 in 2013” (Leger, 2015).

Due to the resurgence in popularity of heroin among IV drug users in recent years, it would seem that fentanyl-laced heroin and the associated use risks and health issues with regard to overdosing are going to be an issue for some time to come.

References
Bond, A. (2016, September 29). Why fentanyl is deadlier than heroin, in a single photo. Retrieved November 10, 2016, from https://www.statnews.com/2016/09/29/fentanyl-heroin-photo-fatal-doses/

DEA Issues Alert on Fentanyl-Laced Heroin as Overdose Deaths Surge Nationwide – Partnership for Drug-Free Kids. (2015, March 19). Retrieved November 10, 2016, from http://www.drugfree.org/news-service/dea-issues-alert-fentanyl-laced-heroin-overdose-deaths-surge-nationwide/

Fentanyl-Laced Heroin Worsening Overdose Crisis, Officials Say – Partnership for Drug-Free Kids. (2015, September 10). Retrieved November 10, 2016, from http://www.drugfree.org/news-service/fentanyl-laced-heroin-worsening-overdose-crisis-officials-say/

Leger, D. L. (2015, March 18). DEA: Deaths from fentanyl-laced heroin surging. Retrieved November 10, 2016, from http://www.usatoday.com/story/news/2015/03/18/surge-in-overdose-deaths-from-fentanyl/24957967/

NIDA (2011). Fentanyl. Retrieved November 10, 2016, from https://www.drugabuse.gov/drugs-abuse/fentanyl

NIDA (1969, rev. October 2014). Heroin. Retrieved November 10, 2016, from https://www.drugabuse.gov/publications/drugfacts/heroin

Teresa King
Pennyroyal Doctoral Intern

November 11 2016

Friday Factoids Catch-Up: New Treatments For Tic Disorders Associated With Tourette’s

Tics, which are characterized by sudden, repetitive, non-rhythmic body movements and/or vocalizations associated with tic disorders and Tourette’s syndrome, are involuntary movements that may involve the hands, shoulder shrugging, eye blinking, etc. In many cases, these tics do not get in the way of living a relatively normal life and consequently little if any treatment is required. At the other end of the spectrum, the tics may be so severe that they require treatment with medication and behavioral therapy, especially if they are causing pain/injury, are interfering with a normal daily routine in one’s education, job performance, or social life, or are responsible for inducing excessive stress. Prior to the treatment of the presenting tics, the presence of other movement-related disorders like chorea, dystonia, as well as the movements displayed by those with autism (stereotypic movement disorder), or those movements manifested as compulsions of OCD or seizure-related activity, must be ruled out to ensure the patient receives the proper care and treatment that is best suited to address his or her needs.

There are various methods for treating the tics that are so often associated with Tourette’s syndrome, including medication, behavioral therapies, and habit reversal. While medication is most often the go-to panacea for controlling tics, the medications themselves may carry side effects that are as bad, or even worse, than the condition that they may be used to treat. Behavioral therapies can also be effective as well by teaching those with Tourette’s to manage their tics. While these can be effective in reducing the number, severity, and impact of the tic behaviors, it is important to realize that behavioral therapy is not a cure, and that although effective it does not mean that tics are merely psychological in their nature. While these treatment methods are effective in aiding the treatment of, and helping to manage, the tic symptoms of Tourette’s syndrome, it is important to note that they are varied in their efficacy, are not one-size-fits-all in their nature, and in the case of medication, may produce unwanted side effects ranging from mild to debilitating in and of themselves.

One of the most promising methods recently developed for the treatment of tics associated with Tourette’s is the Comprehensive Behavioral Intervention for Tics, or CBIT. This new, evidence-based therapy includes the use of education, teaching relaxation techniques, and habit reversal in a combination that is shown to be effective in reducing symptoms of tics and their related impairments, and seems to work equally well for both children and adults. CBIT involves those with Tourette’s working with a therapist to gain a greater understanding of their particular type of tic and learning to recognize situations that worsen tic symptoms. When possible, a change in environment may be initiated, and using habit reversal, a new behavior is modeled so that when the urge to tic occurs, the new behavior is substituted. This method helps to lessen tic occurrences through substituting the new behavior for the tic through repetition, under the guidance of an experienced therapist.

Over the last few years, the number of health professionals that have come to know and appreciate the benefits and effectiveness of CBIT has increased; however, there are still relatively few therapists that have the specific training in these methods of treatment targeted specifically at tic disorders and Tourette’s, and work is currently being done by The Tourette Association of America and the Centers for Disease Control and Prevention to provide education for more health professionals with the training necessary to incorporate and apply this method in their treatment approach to managing the symptoms of Tourette’s and other tic disorders.

References

Cook CR, Blacher J. Evidence-based psychosocial treatments for tic disorders. Clin Psychol: Science and Practice. 2007;14(3):252–67.
Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S. Behavior therapy for children with Tourette disorder: a randomized controlled trial. JAMA. 2010;303(19):1929–37.
Harris, Elana, MD, PhD. Children with tic disorders: How to match treatment with symptoms. Current Psychiatry. 2010 March; 9(3):29-36
Qasaymeh MM, Mink JW. New treatments for tic disorders. Current Treat Options Neurol. 2006 Nov;8(6):465-473

Teresa King
Pennyroyal Intern

October 10 2016

Friday Factoids: Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is a newer diagnosis in childhood that is depicted by extreme irritability, anger, and frequent outbursts (National Institute of Mental Health [NIMH], 2016). Irritability is a clinical symptom of both bipolar disorder and DMDD (Wiggins et al., 2016). Comparatively, irritability in DMDD is “severe and relatively invariant over time,” yet irritability experienced with bipolar disorder may occur while a child is euthymic and may increase during manic or depressive episodes (Wiggins et al., 2016, p. 722). Thus the inclusion of DMDD in part allows for appropriate diagnosis for children with “severe, nonepisodic irritability” that is distinct from bipolar disorder (Wiggins et al., 2016, p. 722).

With DMDD being a new diagnosis, treatment is often based on other disorders with shared symptomatology (e.g., attention-deficit/hyperactivity disorder, anxiety disorders, oppositional defiant disorder, and major depression; NIMH, 2016). Cognitive-behavior therapy (CBT), parent training, and computer-based training are recommended psychological interventions (NIMH, 2016) for DMDD, where as medications may also be considered. For instance, stimulants may help address irritability, antidepressants may mitigate irritability and mood problems, and atypical antipsychotics could be used to alleviate severe outbursts with physical aggression (NIMH, 2016).

The potential for adverse effects with some treatments limit their use in children, resulting in the necessity to explore noninvasive means for treatment (Wiggins et al., 2016). For instance, the use of a video game to reduce the misinterpretation of ambiguous faces in children with irritability has shown to help reduce anger-based reactions found in DMDD. The literature has shown that children with DMDD and bipolar disorder tend to rate neutral faces as angry (Wiggins et al., 2016). Research conducted by Wiggins et al. (2016) has demonstrated that a computer game helped to change the tendency to misinterpret ambiguous faces as angry in irritable children. After training, children were more likely to rate ambiguous faces as happy (Wiggins et al., 2016). Such an intervention may appear superficial, however this research has demonstrated that brain activation patterns when labeling emotional faces differs between DMDD and bipolar disorder (Wiggins et al., 2016). Specifically, amygdala activation related to irritability differed between children with DMDD and bipolar disorder; and temporo-occipital regions of the brain had “associations between irritability and activation in response to ambiguous angry faces” (Wiggins et al., 2016, p. 728).

Thus, differing brain activation patterns helped distinguish the clinical presentation of DMDD versus bipolar disorder (Wiggins et al., 2016). As a result, the authors conclude that though irritability is a common symptom of both DMDD and bipolar disorder, they are in fact distinct disorders and given the different neural correlates, treatments may also be different (Wiggins et al., 2016).

References
National Institute on Drug Abuse (NIDA). (2016). Disruptive Mood Dysregulation Disorder. Retrieved from http://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation-disorder-dmdd/disruptive-mood-dysregulation-disorder.shtml

Wiggins, J. L., Brotman, M. A., Adleman, N. E., Kin, K., Oakes, A. H. Reynolds, R. C.,…Leibenluft, E. (2016). Neural correlates of irritability in disruptive mood dysregulation and bipolar disorders. American Journal of Psychiatry, 173, 722-730.

Dannie S. Harris, MA
WKPIC Doctoral Intern

October 10 2016

Friday Factoids: Methamphetamine Psychosis

As reported by the National Institute on Drug Abuse (NIDA; 2013) methamphetamine use continues to be a significant problem, with over 12 million people or 4.7 percent of the population having tried methamphetamine at least one time. According to NIDA (2013), methamphetamine use can cause memory loss, aggression, psychotic behavior, damage to one’s cardiovascular system, malnutrition, and dental problems.

Chronic use may cause an individual to have difficulty feeling pleasure outside of use, as well as anxiety, confusion, insomnia, mood disturbance, and violent behavior. Psychotic features experienced include paranoia, delusions, and visual, auditory, and tactile hallucinations. Stress has also been related to spontaneous methamphetamine psychosis in individuals who have abused methamphetamine in the past (NIDA, 2013). With acute methamphetamine intoxication individuals may experience hallucinations (auditory, visual, tactile), persecutory, influence, and control delusions, as well as are prone to violence (Zarrabi, Khalkhali, Hamidi, Ahmadi, & Zavarmousavi, 2016).

Even after intoxication passes, psychosis may occur over a prolonged period of time (Zarrabi et al., 2016). Acute psychosis usually has a maximum period of four to five days (Zarrabi et al., 2016); yet, a differing course of psychosis has been documented in the literature. For instance, three clinical groups for stimulant-induced psychosis have been identified: the first group is characterized by transient psychosis, where the duration of symptoms is limited to four or five days and may be associated with withdrawal; with the second group, psychosis is typically resolved in less than one month; and in the third group, psychosis may last several months or years (Zarrabi et al., 2016). It has been estimated that between 5-10% of individuals with methamphetamine-induce psychosis may not fully recover (as cited in Zarrabi et al., 2016).

Risk factors for methamphetamine-induced psychosis are duration, frequency, and amount of use, history of sexual abuse, family history, other substance use, and co-occurring personality and mood disorders (Grant et al., 2012). Of note, substance intoxication is differentiated from a substance/medication-induced psychotic disorder if reality testing for altered perceptions remains intact (American Psychiatric Association, 2013).

Zarrabi, Khalkhali, Hamidi, Ahmadi, and Zavarmousavi (2016) indicate there are no structured treatment guidelines for methamphetamine-induced psychosis. In their study, risperidone and olazapine were most frequently used, as well as benzodiazepines to reduce restlessness. Antipsychotics were reportedly preferred due to better control of violent behaviors. Another study indicated that quetiapine could also be used as an antipsychotic treatment with comparable effects to haloperidol (Verachai et al., 2014). Electroconvulsive therapy (ECT) has been used to control severe aggression and violent behaviors, as well as thoughts of suicide and homicide in methamphetamine-induced psychosis (Zarrabi et al., 2016). Results indicated that after six to nine sessions of ECT, symptoms began to disappear. Though limited by constraints of a case study, Grelotti, Kanayama, and Harrison (2010) again demonstrated the positive effects of ECT on methamphetamine-induced psychosis.

Overall, the most common symptoms with methamphetamine-induced psychosis are paranoid delusions and auditory hallucinations, and such symptoms may prove resistant or refractory to antipsychotic medications (Grelotti, Kanayama, & Pope, 2010). As indicated in the literature, clinicians faced with refractory cases of methamphetamine-induced psychosis may consider ECT as a treatment option.

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.). Washington, DC: Author.

Gerlotti, D., Kanayama, G., & Pope, H. G. (2010). Remission of persistent methamphetamine-induced psyhcosis after electroconvulsive therapy: Presentation of a case and review of literature. The American Journal of Psychiatry, 167(1), 17-23.

Grant, K. M., LeVan, T. D., Wells, S. M., Li, M., Stoltenberg, S. F., Gendelman, H. E.,…BEvins, R. A. (2012). Methamphetamine-associated psychosis. Journal of Neuroimmune Pharmacology, 7(1), 113-139.

National Institute on Drug Abuse (NIDA). (2013). Methamphetamine. Retrieved from https://www.drugabuse.gov/publications/research-reports/methamphetamine

Verachai, V., Rukngan, W., Chaswanakrasaesin, K., Nilaban, S., Suwanmajo, S., Thanateerabunjong, R.,…Kalayasiri, R. (2014). Treatment of methamphetamine-induced psychosis: a double-blind randomized controlled trial comparing haloperidol and quetiapine. Psychopharmacology, 231(16), 3099-3108.

Zarrabi, H., Khalkhali, M., Hamidi, A., Ahmadi, R., & Zavarmousavi, M. (2016). Clinical features, course and treatment of methpahetamine-induce psychosis in psychiatric inpatients. BMC Psychiatry, 16, 1-8.

Dannie S. Harris, MA
WKPIC Doctoral Intern

October 10 2016

Friday Factoids: Working With Children Who Have Early-Onset Schizophrenia

Though diagnostic criteria for early-onset schizophrenia are the same for adults and children, the treatment approach may differ. For instance, discussing the symptoms of psychosis with children can be challenging. Often parental report is utilized when discussing symptoms; however, as noted by Caplan (2011), parents may be unaware of the experience of hallucinations by their child.

Children may not spontaneously talk about hallucinations due to others negating the experience (e.g., It’s nothing; It’s only your imagination), being scared to talk about it, feeling they will burden their parents with it, or believing that talking about the hallucination will make it happen (Caplan, 2011). Clinicians should use careful wording to ask about hallucinations. Delusions, like hallucinations, should be differentiated from normal developmental phenomena (e.g., fantasies, magical thinking; Caplan, 2011). Though morbid fantasies may be upsetting, they too are common (Caplan, 2011); however, if they are pervasive and acted upon they might be “precursors of delusions” (Caplan, 2011, p. 60). Disorganized speech and thought disorders are reflected in illogical thinking, loose associations, and impaired discourse skills (Caplan, 2011; Shatkin, 2015). This communication difficulty must be distinguished from language problems related to language disorders or intellectual disability (Caplan, 2011; Stentebjerg-Olesen et al., 2016); thus it may be beneficial to refer to speech or language therapist to help clarify diagnoses.

Compared to adults, negative symptoms are more prominent in children and adolescents (Harvey, James, & Shields, 2016). Additionally, negative symptoms are noted to be predictors of poorer clinical and functional outcomes (Harvey et al., 2016). Other symptoms related to early-onset schizophrenia are abnormalities of gait, posture, and muscle tone (Shatkin, 2015).

Given the trajectory and progressive course of schizophrenia, early identification and intervention should be emphasized, especially in light of the findings that longer duration of untreated psychosis and poorer premorbid adjustment are associated with poorer outcomes (Stentebjerg-Olesen, Pagsberg, Fink-Jensen, Correll, & Jeppesen, 2016). Furthermore, early-onset schizophrenia is often refractory to treatment. Recent research has indicated that clozapine demonstrated greater efficacy compared to other antipsychotics (Kasoff, Ahn, Gochman, Broadnax, & Rapoport, 2016), where as other research (Harvey et al., 2016) demonstrated that antipsychotics showed a trend of reduction of symptoms compared to placebos, but only olanzapine and risperidone demonstrated statistically significant improvements for positive symptoms, as well as general psychopathology as measured by the Positive and Negative Syndrome Scale (PANSS).

References
Caplan, R. (2011). Childhood schizophrenia: Diagnostic and treatment challenges. Cutting Edge Psychiatry in Practice, 3(1), 55-67.

Harvey, R. C., James, A. C., & Shields, G. E. (2016). Assess the relative efficacy of antipsychotics for the treatment of positive and negative symptoms in early-onset schizophrenia. CNS Drugs, 30(1), 27-39.

Kasoff, L. I., Ahn, K., Gochman, P., Broadnax, D. D., & Rapoport, J. L. (2016). Strong treatment response and high maintenance rates of clozapine in childhood-onset schizophrenia. Journal of Child and Adolescent Psychopharmacology, 26(5), 428-435.

Shatkin, J. P. (2015). Child & adolescent mental health: A practical, all-in-one guide. New York: W. W. Norton & Company.

Stentebjerg-Olesen, M., Pagsberg, A. K., Fink-Jensen, A., Correll, C. U., & Jeppesen, P. (2016). Clinical characteristics and predictors of outcome of schizophrenia-spectrum psychosis in children and adolescents: A systematic review. Journal of Child and Adolescent Psychopharmacology, 26(5), 410-427.

Dannie S. Harris
WKPIC Doctoral Intern

Previous page 1 … 11 12 13 14 15 … 33 Next page

Innovative Psychology Internship Program in Western Kentucky. See what we are all about!

Teaching Excellence

Category Archives: Mental Health and Wellness

Friday Factoids Catch-Up: Heroin and Fentanyl–A Match Made in Hell

Friday Factoids Catch-Up: New Treatments For Tic Disorders Associated With Tourette’s

Friday Factoids: Disruptive Mood Dysregulation Disorder

Friday Factoids: Methamphetamine Psychosis

Friday Factoids: Working With Children Who Have Early-Onset Schizophrenia

Phone: 270-889-2741

Phone: 270-889-2811