Dual Diagnosis

Definition

Dual diagnosis refers to the co-existence of mental health disorder(s) and substance related disorder(s) (alcohol and/or drug dependence or abuse). The mental health disorder(s) and the substance related disorder(s) are equally important and independent (but invariably interactive)disorders.

Note:

Recreational chemical use can magnify preexisting mental disorders or bring about a drug-induced disorder that simulates any of a wide range of mental problems. These drug induced complications usually diminish or entirely disappear shortly after the client stops abusing recreational drug(s); thus they might be said to substance-induced.

Criteria

Dual diagnosis can include the following:

  1. Severe mental illness and a substance disorder.
  2. Substance disorder and a personality disorder.
  3. Substance disorder, personality disorder and substance induced acute symptoms that may require psychiatric care, i.e. hallucinations, depression and other symptoms resulting from substance misuse or withdrawal.
  4. Substance misuse, mental illness, and physical illnesses which may be a result of substance misuse, or independent of substance misuse.

Statistics

Nationwide, almost 4 million Americans have co-occurring serious mental illness and substance abuse problems, according to SAMHSA's latest household survey. This number would be much higher if it reflected less severe mental illnesses or less severe substance use problems.

At least 50% of the 2 million Americans with severe mental illness abuse illicit drugs or alcohol, compared to 15% of the general population, according to the Alcohol, Drug Abuse, and Mental Health Administration.

According to a recent report published by the Journal of the American Medical Association:

  • 37% of people who abuse alcohol cope with a psychiatric disorder.
  • 53% of people with a drug addiction also have a mental illness.
  • 29% of people with a psychiatric disorder have a substance abuse problem.

The following chart based on a National Institute of Health study, lists the overlap between substance related disorders and various mental health disorders.

Mental Health DisorderLifetime Prevalence of Substance Related Disorder

Depression32%

Bipolar affective disorder 64%

Anxiety disorder36%

Antisocial disorder84%

Schizophrenia50%

Causes

The causes of psychiatric disorders and substance related disorders are complex. The evidence that people with mental health disorders are more likely to abuse substances, or vice versa, that those people who abuse substances are more likely to develop some form of mental health disorder indicates that the causes are likely to be complex. This is highlighted below:

  • Substance use can cause psychiatric symptoms and mimic psychiatric symptoms
  • Substance use can initiate or worsen a psychiatric disorder
  • Substance use can mask psychiatric symptoms
  • Substance withdrawal can cause psychiatric symptoms and mimic psychiatric disorders
  • Psychiatric behaviors can mimic substance use problems
  • Substance use can make side effects from medication worse, and more likely to occur.

Signs and Symptoms

The symptoms that a person with dual diagnosis exhibits tend to be identified in two parts which is sometimes why one diagnosis is mixed. The symptoms associated with any major psychiatric disorder, such as schizophrenia, bipolar mood disorder, or personality disorder is identified. Then many times the issues associated with abuse of alcohol and/or other drugs are then identified. This may occur in the opposite order as well. Some signs and symptoms to be familiar with in the dual diagnosis population are as follows but would also include the combination of those signs and symptoms for both substance related disorders and the various different psychiatric disorders.

  • Family problems or problems in intimate relationships
  • Isolation and social withdrawal
  • Financial problems
  • Employment or school problems
  • High risk behavior while driving
  • Multiple admission for chemical dependency services due to relapse
  • Multiple admissions for psychiatric care
  • Increased casualty/accident and emergency admissions
  • Increase need for health care services
  • Legal problems and possible incarceration
  • Homelessness

Course of Illness

The impact of being dually diagnosed means that a person often experiences more severe and chronic medical, social and emotional problems than if they were to just have one diagnosis. They are vulnerable of not only an alcohol and other drug relapse but also a relapse of their mental health problems. The occurrence of either of these is likely to affect the other in a negative way. Treatment and relapse prevention must therefore be specifically catered towards the person, and will often take longer, come across more obstacles, and progress only gradually.

Both substance abuse and untreated mental illness are associated with a greater risk of suicide. It is estimated that 16% of all substance abusers will die by suicide. Research shows that individuals with a dual diagnosis are at a further increased risk of suicide. This increased risk may be due to the person's illness worsening and becoming more at risk of a suicide attempt. Substance abuse has been shown to play a key role in the transition from suicidal thoughts in people with mental illness to actual suicide attempts. Severe depression accompanied by substance misuse is one of the most frequent causes of suicide. Dual diagnosis is also associated with an increased risk of violence to others. Aggression is another factor which increases the risk of suicide.

Treatment

There are a range of theories of co-occurring disorders that can be grouped into the following four models: 1) common factors increase the risk for both mental and substance disorders; 2) mental health disorders increase the risk for substance related disorders; 3) substance related disorders increaser the risk for mental health disorders; and 4) the relationship between the two types of disorders is reciprocal or bi-directional.

Whatever the explanation, when a person has mental and substance related disorders, both disorders generally require treatment. Whether the mental health disorder precedes the substance related disorder or vice versa, the substance related disorder is unlikely to disappear by treating the mental health disorder, and the mental health disorder is unlikely to disappear by treating the substance related disorder.

There are three broad treatment models for dually diagnosed individuals:

1)Sequential treatment: where one treatment, either mental health or substance related disorder is followed by the other;

2)Parallel treatment: the concurrent but separate treatment of both mental health disorder and substance related disorder; and

3)Integrated treatment: where substance misuse and mental health treatment are provided concurrently by the same personnel.

Both mental health disorders and substance related disorders are relapsing conditions with frequent exacerbation and individuals with dual diagnosis disorders are seen as more challenging to treat and as having poorer outcome prognoses than individuals with single disorders. Often treatment problems occur as a result of a treatment system compartmentalized into substance related services and mental health services with few or no connections. Frequently service providers are not cross trained, come from different disciplines, and have differing treatment and outcome philosophies.

Ideally both problems are treated simultaneously. In cases in which the substance related requires detoxification this would be the first step of treatment. This is a period of time during which the body is cleansed of substances. This step can take any where from a few days to a week or more, depending on what substance the person abused and for how long. Ideally, detoxification should take place under medical supervision. This helps to ensure a safer and less traumatic detoxification process. Once detoxification (if necessary) is completed a simultaneous treatment can commence.

Dual Disorder Recovery Counseling developed by Dennis Daley

This is an integrated approach to the treatment of persons with both substance related disorder(s) and psychiatric disorder(s). This includes individual and group counseling focusing on addiction counseling and psychiatric interventions. Other interventions in addition to counseling include: education about alcohol and drugs, education about the particular psychiatric condition, exercise, proper nutrition, 12-step recovery, psychiatric specific support group, and medication management. Family involvement is encouraged.

There are four phases of dual diagnosis treatment that include: engagement, persuasion, active treatment, and relapse prevention.

  • Engagement/stabilization – build working alliance and begin to establish trust and credibility; stabilize acute symptoms of psychiatric and substance related disorders
  • Persuasion – involves helping the individual to comprehend the need to seriously address the disorders; help individual to see the discrepancies between goals and current behavior to create impetus for change; link substance use and psychiatric symptoms and explore their impact on each other to help understand the problem
  • Active treatment – achieving and maintaining abstinence from substances or, for individuals unable or unwilling to work toward total abstinence, reducing the amount and frequency of use and concomitant biopsychosocial components associated with substance use disorders; stabilizing acute psychiatric symptoms; resolving or reducing problems and improving physical, emotional, social, family, interpersonal, occupational, academic, spiritual, financial, and legal functioning; working toward positive lifestyle change
  • Relapse prevention – reinforce gains made in previous stages; early intervention in the process of relapse to either the substance related or psychiatric disorder

Persons best suited for this treatment approach include any range of type of addiction, mental health disorder, or combination or dual disorders. Those persons best suite for this treatment approach include mood, anxiety, schizophrenia, adjustment, and other addictive disorders, in combination with substance related disorders. Those individuals less suited for this approach include: mental retardation, organic brain syndromes, head injuries, and more sever forms of thought disorders.

Five principles that may help you counsel dually diagnosed individuals more effectively.

  • Appreciate this population’s heterogeneity
  • Adopt a longitudinal treatment approach, reassessing the individual’s progress and adjusting interventions as needed over time
  • Be empathetic rather than confrontational
  • Realize that treatment often proceeds in stages or phases not on a smooth, linear path
  • Recognize the importance of medication management

Determining Level of Care of Treatment Facility

The nature and severity of the disorders, the associated risks or complications, and the person’s treatment history are some of the factors to consider in determining the appropriate level of care. There are several different levels or intensities of care from full hospitalization or inpatient treatment to partial hospitalization to residential to intensive outpatient to outpatient treatment. Inpatient dual-diagnosis treatment usually last up to three weeks. Longer term specialty residential treatment programs may last from several months to a year or more. Partial hospitalization programs usually last from six to twelve months. Outpatient treatment tends to last six months or longer. Recurrent conditions, such as certain depressive disorders and bipolar disorder and persistent disorders such as schizophrenia, typically require ongoing counseling and medication management.

Accommodations

Accommodations for individuals with Dual Diagnosis are going to be heterogeneous, much like the population of individuals with Dual Diagnosis. They will also need to be individually derived based upon the needs of the specific client. A good starting point is to visit the Job Accommodations Network accommodations toolbox and to look at both Psychiatric Impairments and Alcohol/Chemical issues.

Recommended Readings & Resources

Daley, D.; Moss, H.; and Campbell, F. Dual Disorders: Counseling Clients with Chemical Dependency and Mental Illness. 2d ed. Center City, MN: Hazelden, 1993.

Meyer, R., ed. Psychopathology and Addictive Disorders.New York: Guilford Press, 1986.

Sciacca, Kathleen, Removing Barriers: Dual Diagnosis Treatment and Motivational Interviewing,Psychological Counselor, February, 1997.

Drake,R.E.,Mueser,K.T.,Clark,R.E.,&Wallach,M.A.(1996) The course,treatment and outcome of substance disorder in persons with severe mental illness. American Journal of Orthopsychiatry. (66),42-51.

Dual Recovery Anonymous World Services Central Office
P.O. Box 8107
Prairie Village, KS66208
Phone: 877-883-2332

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