Dual Diagnosis and Co-existing Conditions

A Dual Diagnosis Definition

Research indicates that more and more individuals suffer from the combination of substance abuse (alcohol or drugs) and a mental health disorder. Addiction itself is considered a mental health disorder because of the changes it causes within the brain. These chemical changes disrupt a person’s hierarchy of needs, desires, and priorities. The combination of a mental health disorder, such as depression, bipolar, or anxiety disorder, and substance abuse is a “dual diagnosis disorder.” According to the Journal of the American Medical Association:

Roughly 50% of individuals with severe mental disorders are affected by substance abuse
37% of alcohol abusers and 53% of drug abusers also have at least one serious mental illness
Of all people diagnosed as mentally ill, 29% abuse either alcohol or drugs

(source: National Alliance of Mental Illness)

There are a number of factors that lead to the combination of a substance abuse problem and a mental illness. Generally, there are three situations: substance abuse causes the mental illness, the mental illness causes substance abuse, or mental disorders and substance abuse are attributable to other risk factors.

According to the National Institute of Drug Abuse, people suffering from a dual diagnosis exhibit more severe symptoms than those caused by either condition alone. An appropriate diagnosis, treatment plan, and aftercare plan are crucial to the successful recovery from a dual diagnosis. Ongoing management is a core component of any treatment plan.

Medical facilities often do not provide medications to stabilize a mental illness combined with a substance addiction (as it may go undiagnosed), or attending physicians may not treat a mental illness. To further complicate diagnosis and treatment, research has found that certain mental health disorders are more prominent in one gender than the other. For example, “among men and women in drug treatment, antisocial personality disorder is more common in men, while women have higher rates of major depression, post-traumatic stress disorder, and other anxiety disorders.” (http://drugabuse.gov/tib/comorbid.html)

Mental health disorders are categorized by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a medical reference published by the American Psychiatric Association. The book provides doctors, psychiatrists, and therapists with criteria to diagnosis mental disorders, along with “axis numbers” used for classification. The Axis I classification is for clinical disorders, such as depression, anxiety, bipolar, ADHD, autism spectrum disorders, phobias, schizophrenia and substance abuse. Axis II covers personality disorders and mental retardation, including paranoid personality disorder, schizoid personality disorder, borderline personality disorder, antisocial personality disorder, and obsessive-compulsive disorder. Axes III-V include stressors, family problems, and the social environment, among others.

When compared with people who have a mental health problem alone, people with a dual diagnosis are more likely to have:

Increased likelihood of suicide
More severe mental health problems
Homelessness and unstable housing
Increased risk of being violent
Increased risk of victimization
More contact with the criminal justice system
Family problems
History of childhood abuse (sexual/physical)
More likely to slip through net of care
Less likely to be compliant with medication and other treatment

(The Royal College of Psychiatrists Research Unit , http://www.penninecare.nhs.uk/documents/ddipPracManual.pdf)

Substance-Induced Mental Disorders

When a person going into detox for drugs or alcohol displays symptoms of a mental disorder, it is not always clear whether that disorder is an underlying factor of drug and alcohol abuse, or a secondary response to the drug and alcohol addiction. This reality makes it more difficult for a treating psychiatrist to make the appropriate dual diagnosis. After detox has been completed, a thorough psychiatric exam must take place. Substance-induced mental disorders that may present themselves at detox include:

Substance-induced delirium
Substance-induced persisting dementia
Substance-induced persisting amnesic disorder
Substance-induced psychotic disorder
Substance-induced mood disorder
Substance-induced anxiety disorder
Hallucinogen persisting perceptual disorder
Substance-induced sexual dysfunction
Substance-induced sleep disorder

(DSM-IV, 2000, p. 209)

The severity of these conditions cannot be underestimated. They are dangerous. For example, someone suffering from substance-induced depression is at a great risk of suicide and other self-injurious behaviors. Studies indicate that alcohol patients “had 60-120 fold greater risk of death by suicide than did the general population….[A 1996 study examining] patients who had been hospitalized psychiatrically…found that more than half of the subjects in all three groups…(those with alcohol dependence, cocaine dependence, or alcohol plus cocaine dependence) had a history of suicide attempts.” Once the substance has left the body, severe symptoms can emerge. Anxiety symptoms among newly sober alcoholics were high.

A correct dual diagnosis is crucial to developing the appropriate treatment plan. “Making the diagnosis of a substance use disorder is the first step in the differential diagnosis and treatment of substance-related problem. In the second step, the substance-induced symptoms must be differentiated from the symptoms of major psychiatric disorders. Finally, the substance-induced disorders must be differentiated from the dual disorders…” (American Society of Addiction Medicine, 2003, Ch 1, Section II, pp. 1265-68)

Mental health disorders that are present irrespective of substance abuse can be exacerbated by the use of drugs and alcohol. Intrusive thoughts and terrifying dreams will worsen with those suffering from PTSD, for example. These substance-induced symptoms can persist long after drugs or alcohol have left the body.

Co-Existing Conditions

While a patient may suffer from a dual diagnosis disorder, he or she may also suffer from other mental and medical issues that are considered co-existing conditions. Perhaps the person suffers from a gambling addiction coupled with tremendous grief. Or a patient has a compulsive spending problem coupled with lack of success in school and the inability to follow a project through to completion. A patient after years of substance abuse may have cirrhosis of the liver and depression. These conditions exist simultaneously but are not directly related, thus are considered co-existing or co-occurring conditions. To diagnose these conditions, a doctor or therapist may examine the following areas of concern:

Attitude
Appearance and behavior, including psychomotor activity
Speech
Mood
Thought processes, including suicidal ideas, plans, and intentions
Delusions
Perceptual disturbances and hallucinations
Cognition, including orientation, attention, concentration, memory, and intelligence
Judgment and capacity to consent to treatment
Insight
Medical conditions

Adapted from (http://www.penninecare.nhs.uk/documents/ddipPracManual.pdf)

It is not unusual, however, to find patients suffering from a host of Axis I, Axis II, and co-existing conditions at the same time. Thus, the treatment team must untangle mental health (DSM-IV), substance abuse, and social issues to get an accurate understanding of a patient’s real condition and the controlling bio/psycho/social dynamics. Regardless, a patient receiving treatment must address the power exerted by these combined disorders to stabilize his or her condition.