Dual diagnosis


Dual diagnosis

The term dual diagnosis is used to describe the comorbid condition of a person considered to be suffering from a mental illness and a substance abuse problem. There is considerable debate surrounding the appropriateness of the term being used to describe a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly, for example depression and alcoholism, or it can be restricted to specify severe mental illness (e.g. psychosis, schizophrenia) and substance misuse disorder (e.g. cannabis abuse), or a person who has a milder mental illness and a drug dependency, such as panic disorder or generalized anxiety disorder and is dependent on opioids. Dual diagnosis is also a term used for people with an intellectual disability and diagnosed with a mental illness. Making a dual diagnosis in substance abusers is difficult as drug abuse itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance induced and pre-existing mental illness.

Contents

Overview

Dual Diagnoses have been neglected for a long time. Dual diagnosis is also used to describe a co-occurring condition in which a person is simultaneously diagnosed with an Axis I and an Axis II psychiatric disorder. While Axis I conditions are considered more or less amenable to treatments such as individual therapy and psychotropic drugs (e.g., antipsychotic, anxiolytic, and antidepressant medications), Axis II conditions are typically considered more resistant or even refractory to such treatments.

Common Axis I conditions that may be treated though drug therapy, counseling, or a combination of the two include (but are not limited to) major depressive disorder, obsessive-compulsive disorder, generalized anxiety disorder, delusional disorder, and schizophrenia. Axis II conditions are limited to mental retardation and the personality disorders such as borderline personality disorder and antisocial personality disorder.

These conditions were originally separated from the Axis I conditions to highlight their intractability to treatment, although there is some evidence to suggest that personality disorders may be managed through long-term individual therapy. The fact that autistic disorder is coded on Axis I is one of the many criticisms of the DSM-IV-TR (the diagnostic manual for mental disorders published by the American Psychiatric Association), as this falsely implies that austic disorder can be "cured" through popular but fad treatments. Emerging literature has proved that dual diagnosis has become a contemporary issue that require a multidimensional service delivery system in order to meet the needs of people with comorbidity conditions.(Regier,1990 and Hall,1996) agrees that “ It is a well-known, but poorly addressed fact that drug and alcohol problems often co-exist with mental disorders.”

The first treatment interventions and integrated treatment approach for people who had dual diagnosis began in 1984 in the New York State Office of Mental Health system (Sciacca, 1987, 1991, 1996). This began in an outpatient mental health clinic and expanded to a New York State-wide initiative. The MICAA training site for program and staff development New York State-wide was created specifically for workforce development and program implementation across NY State. This initiative crossed systems to include substance abuse programs, homeless services, criminal justice services and more. It included inpatient, outpatient and residential treatment. This initiative included clinical materials including screening, assessment, outcome measures and treatment materials; curriculum and training materials; program development and implementation materials (Sciacca, 1990). This treatment approach, training curriculum and program implementation model was also adapted across systems in various states including Michigan (Sciacca, 1995 and Sciacca & Thompson, 1996). It included programs for the families of the dually diagnosed (Sciacca & Hatfield, 1995) and consumer led self-help programs (Sciacca, 1997). A specific curriculum served as an addendum to the SAMHSA-CMHS Managed Care Initiative Co-Occurring disorder report (Sciacca, 1998). Other states and cities who initiated this model include Tennessee, Alaska, Georgia, Kentucky, Washington DC, Dallas, Texas, among numerous others (Sciacca, 1995, 1997, 1998, 1999, 2001, 2003). In 1993 evidence based models including motivational interviewing, the stages of change and cognitive behavioral therapy correlates were integrated into the dual diagnosis treatment model and comprise the treatment approach and integrated care model that exists today (Sciacca, 1997, 2007, 2008, 2009, 2011).

However research has shown that there are only a few if any institutions that are geared to address the complex needs of people with dual diagnosis (Crawford, 2001). This brings the fact in agreement to Reisis discovery that despite the increase of dual diagnosis both in Australia and across the world; service distribution systems requires to be improved meet the needs of this group (Reiss, 1992).With this in mind one would agree that this issue has been historically neglected and there has been limited attention which has indirectly contributed to poor services to people with dual diagnosis (Allsop, 2008).

Differentiating pre-existing and substance induced

Drug abuse, including alcohol and prescription drugs can induce symptomatology which resembles mental illness which can make it difficult to differentiate between substance induced psychiatric syndromes and pre-existing mental health problems. More often than not psychiatric disorders among drug or alcohol abusers disappear with prolonged abstinence. Substance induced psychiatric symptoms can occur both in the intoxicated state and also during the withdrawal state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate alcohol sustained use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence. A protracted withdrawal syndrome can also occur with psychiatric and other symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use.[1]

Prevalence

One US study attempting to assess the prevalence of dual diagnosis found that 47% of the people they worked with, who had schizophrenia, had a substance misuse disorder at some time in their life and that the chances of developing a substance misuse disorder was significantly higher among patients suffering from a psychotic illness than in the general population without a psychotic illness.[2][3]

Another study looked at the extent of substance misuse in a group of 187 chronically mentally ill patients living in the community. According to the clinician's ratings, around a third of the sample used alcohol, street drugs, or both during the six months before evaluation.[4]

Further UK studies have shown slightly more moderate rates of substance misuse among mentally ill individuals. One study found that individuals suffering from schizophrenia showed just a 7% prevalence of problematic drug use in the year prior to being interviewed and 21% reported problematic use some time before that.[5]

Wright and colleagues identified individuals with psychotic illnesses who had been in contact with services in the London borough of Croydon over the previous 6 months. Cases of alcohol or substance misuse and dependence were identified through standardized interviews with clients and keyworkers.

Results showed that prevalence rates of dual diagnosis were 33% for the use of any substance, 20% for alcohol misuse only and 5% for drug misuse only. A lifetime history of any illicit drug use was observed in 35% of the sample.[6]

Diagnosis

Substance use disorders can be confused with other psychiatric disease. There are diagnoses for substance-induced mood disorders and substance-induced anxiety disorders and thus such overlap can be complicated. For this reason, the DSM-IV advises that diagnoses of primary psychiatric disorders not be made in the absence of sobriety (of duration sufficient to allow for any substance-induced symptoms to dissipate).

Treatment

It can be very difficult to find appropriate treatment opportunities for these people.[7] Most substance-abuse centers do not accept people with serious psychiatric conditions, and many psychiatric centers do not have expertise with substance abuse.

However, principles do exist for successful treatment of individuals with coexisting mental and substance-abuse disorders.[8] Treatment of the two disorders should be integrated, not separate, and should be a collaborative decision-making process between the treatment team and the patient. Recovery needs to be viewed as a marathon, not as a sprint, and methods and outcome goals should be explicit. Although many patients may reject medications as antithetical to substance-abuse recovery and side effects, they can be useful to reduce paranoia, anxiety, and craving. Medications that have proven effective include opioid replacement therapies, such as life-long maintenance on methadone or buprenorphine, to minimize risk of relapse, fatality, and legal trouble amongst opioid addicts, as well as helping with cravings, baclofen for alcoholics, opioid addicts, cocaine addicts, and amphetamine addicts, to help eliminate drug cravings, and clozapine, the first atypical antipsychotic, which appears to reduce illicit drug use amongst stimulant addicts. Clozapine can cause respiratory arrest when combined with alcohol, benzodiazepines, or opioids, so it is not recommended to use in these groups.

Theories of dual diagnosis

A number of theories to explain the relationship between mental illness and substance abuse exist. Mueser et al.[9] have identified several theories that attempt to explain the mental illness-substance misuse relationship.



Causality

The causality theory suggests that certain types of substance abuse may causally lead to mental illness. Though causality in epidemiological studies can be difficult to establish, some evidence supporting a causal link between use of cannabis, and later development of psychosis such as schizophrenia exist.[10]

This theory has been challenged as despite explosive increases in cannabis consumption over the past 40 years in western society, the rate of schizophrenia (and psychosis in general) has remained relatively stable.[11][12][13] For this theory to be correct, other factors which are thought to contribute to schizophrenia would have to have converged almost flawlessly to mask the effect of increased cannabis usage. However, increases in the incidence of bipolar disorder, generalized anxiety disorder, and attention deficit-hyperactivity disorder have occurred nearly simultaneously with increases in cannabis use, mirroring rapid increase—though this could be due to a broadening of the diagnostic criteria for such disorders, and/or possibly a growing tendency to "medicalize" behavioral problems and deviance.[14]

Statistics linking the incidence of schizophrenia and cannabis usage cannot ever demonstrate true causality or a lack of it (in a statistical sense, not in terms of causality as a theory on the causes of schizophrenia), however over long time periods with large samples, it appears exceedingly unlikely that cannabis usage could be causal in the development of schizophrenia. For this reason and because of the range of other viable theories regarding the causes of schizophrenia, studies claiming to show causality have tended to be met with caution by healthcare professionals.

Past exposure to psychiatric medications theory

The Past-exposure theory suggests psychiatric medication can alter neural synapses, introducing an imbalance that wasn’t there before; withdraw the drug and the patient seems to do much worse, then “recovers” once returned to the drug or another one in the same class. It may appear as if the medication is working, when in fact, it’s only treating a disorder that the psychiatric drugs created. The disorders created by the use of psychiatric drugs can resemble mental illness and a substance abuse disorders in many cases.

Self-medication theory

The self-medication theory suggests that people with severe mental illnesses misuse substances in order to relieve a specific set of symptoms and counter the negative side-effects of antipsychotic medication.[15]

Khantizan proposes that substances are not randomly chosen, but are specifically selected for their effects. For example, using stimulants such as nicotine or amphetamines can be used to combat the sedation that can be caused by higher doses of certain types of (usually typical) antipsychotic medication. Conversely, some people taking medications with a stimulant effect such as the SNRI antidepressants Effexor (venlafaxine) or Wellbutrin (bupropion) may seek out benzodiazepines or opioid narcotics to counter the anxiety and insomnia that such medications sometimes evoke.

Some studies show that nicotine administration can be effective for reducing motor side-effects of antipsychotics, with both bradykinesia[16] (stiff muscles) and dyskinesia[17](involuntary movement) being prevented.

Alleviation of dysphoria theory

The alleviation of dysphoria theory suggests that people with severe mental illness commonly feel bad about themselves and that this makes them vulnerable to using psychoactive substances to alleviate these feelings. Despite the existence of a wide range of dysphoric feelings (anxiety, depression, boredom, and loneliness), the literature on self-reported reasons for use seems to lend support for the experience of these feelings being the primary motivator for drug and alcohol misuse.[18]

Multiple risk factor theory

Another theory is that there may be risk factors that can lead to both substance abuse and mental illness. Mueser hypothesizes that these may include factors such as social isolation, poverty, lack of structured daily activity, lack of adult role responsibility, living in areas with high drug availability, and association with people who already misuse drugs.[19][20]

Other evidence suggests that traumatic life events such as sexual abuse, are associated with the development of psychiatric problems and substance abuse.[21]

The supersensitivity theory

The supersensitivity theory[22] proposes that certain individuals who have severe mental illness also have biological and psychological vulnerabilities, caused by genetic and early environmental life events.

These interact with stressful life events and result in either a psychiatric disorder or trigger a relapse into an existing illness. The theory states that although anti-psychotic medication can reduce the vulnerability, substance abuse may increase it, causing the individual to be more likely to experience negative consequences from using relatively small amounts of substances.

These individuals therefore, are "supersensitive" to the effects of certain substances and suggest that individuals with psychotic illness such as schizophrenia may be less capable of sustaining moderate substance use over time without experiencing negative symptoms.

Although there are limitations in the research studies conducted in this area, namely that most have focused primarily on schizophrenia, this theory provides a good rationale as to why relatively low levels of substance misuse often result in negative consequences for individuals with severe mental illness.[22]

Footnotes

  1. ^ Evans, Katie; Sullivan, Michael J. (1 March 2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser (2nd ed.). Guilford Press. pp. 75–76. ISBN 978-1572304468. http://books.google.com/?id=lvUzR0obihEC. 
  2. ^ Kessler RC; McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen HU, Kendler KS (1994). "Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey". Archives of General Psychiatry 51 (1): 8–19. doi:10.1001/archpsyc.51.1.8. PMID 8279933. 
  3. ^ Regier DA; Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK (1990). "Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study". JAMA 264 (19): 2511–18. doi:10.1001/jama.264.19.2511. PMID 2232018. 
  4. ^ Drake RE; Wallach MA (1993). "Moderate drinking among people with severe mental illness". Hospital & Community Psychiatry 44 (8): 780–2. PMID 8375841. 
  5. ^ Cantwell, R; Scottish Comorbidity Study Group (2003). "Substance use and schizophrenia: effects on symptoms, social functioning and service use". British Journal of Psychiatry 182 (4): 324–9. doi:10.1192/bjp.182.4.324. PMID 12668408. http://bjp.rcpsych.org/cgi/content/full/182/4/324. Retrieved 2008-02-26. 
  6. ^ Wright S; Gournay K, Glorney E, Thornicroft G (2000). "Dual diagnosis in the suburbs: prevalence, need, and in-patient service use". Social Psychiatry & Psychiatric Epidemiology 35 (7): 297–304. doi:10.1007/s001270050242. PMID 11016524. 
  7. ^ NAMI | Dual Diagnosis - Substance Abuse and Mental Illness
  8. ^ Green MD (March 19, 2009). "Development of a Dual Disorders Program Methodology for Better Outcomes". Psychiatric Times. http://www.psychiatrictimes.com/paranoia/article/10168/1390341. 
  9. ^ Mueser KT; Essock SM, Drake RE, Wolfe RS, Frisman L (2001). "Rural and urban differences in patients with a dual diagnosis". Schizophrenia Research 48 (1): 93–107. doi:10.1016/S0920-9964(00)00065-7. PMID 11278157. 
  10. ^ Moore TH; Zammit S, Lingford-Hughes A, Barnes TR, Jones PB, Burke M, Lewis G (2007). "Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review". The Lancet 370 (9584): 319–28. doi:10.1016/S0140-6736(07)61162-3. PMID 17662880. 
  11. ^ Degenhardt L, Hall W, Lynskey M (2001) (PDF). Comorbidity between cannabis use and psychosis: Modelling some possible relationships.. Technical Report No. 121.. Sydney: National Drug and Alcohol Research Centre.. http://ndarc.med.unsw.edu.au/NDARCWeb.nsf/resources/TR_18/$file/TR.121.PDF. Retrieved 2006-08-19. 
  12. ^ Martin Frisher, Ilana Crome, Orsolina Martino, and Peter Croft. (2009). "Assessing the impact of cannabis use on trends in diagnosed schizophrenia in the United Kingdom from 1996 to 2005". Schizophrenia Research 113 (2–3): 123–128. doi:10.1016/j.schres.2009.05.031. PMID 19560900. http://www.ukcia.org/research/keele_study/Assessing-the-impact-of-cannabis-use-on-trend-in-diagnosed-schizophrenia.pdf. 
  13. ^ http://www.nhsconfed.org/Publications/Documents/MHN_factsheet_August_2009_FINAL_2.pdf Key facts and trends in mental health, National Health Service, 2009
  14. ^ http://www.vancouversun.com/Psychiatry+bible+could+roll+whole+list+disorders/2951855/story.html Psychiatry's `bible' could roll out a whole new list of disorders - and more prescriptions for psychoactive drugs. By Sharon Kirkey, Canwest News Service, April 25, 2010
  15. ^ Khantzian EJ (1997). "The self-medication hypothesis of substance use disorders: a reconsideration and recent applications". Harv Rev Psychiatry 4 (5): 231–44. doi:10.3109/10673229709030550. PMID 9385000. 
  16. ^ Yang YK, Nelson L, Kamaraju L, Wilson W, McEvoy JP (October 2002). "Nicotine decreases bradykinesia-rigidity in haloperidol-treated patients with schizophrenia". Neuropsychopharmacology 27 (4): 684–6. doi:10.1016/S0893-133X(02)00325-1. PMID 12377405. 
  17. ^ Silvestri S, Negrete JC, Seeman MV, Shammi CM, Seeman P (April 2004). "Does nicotine affect D2 receptor upregulation? A case-control study". Acta Psychiatr Scand 109 (4): 313–7; discussion 317–8. doi:10.1111/j.1600-0447.2004.00293.x. PMID 15008806. http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0001-690X&date=2004&volume=109&issue=4&spage=313. 
  18. ^ Pristach CA; Smith CM (1996). "Self-reported effects of alcohol use on symptoms of schizophrenia". Psychiatr Serv 47 (4): 421–3. PMID 8689377. 
  19. ^ Anthony, J.C. & Helzer, J.E. 1991, "Syndromes of drug abuse and dependence", in Psychiatric Disorders in America: The Epidemiologic Catchment Area Study, L.N. Robins & D.A. Regier, eds., Free Press, New York, pp. 116-154.
  20. ^ Berman, S; Noble, EP (1993). "Childhood antecedents of substance misuse". Current Opinion in Psychiatry 6 (3): 382–7. doi:10.1097/00001504-199306000-00012. 
  21. ^ Banerjee, S., Clancy, C., & Crome, I. 2002, "Co-existing Problems of Mental Disorder and Substance Misuse (dual diagnosis). An Information Manual. Found at http://www.rcpsych.ac.uk", Royal College of Psychiatrists' Research Unit.
  22. ^ a b Mueser KT; Drake RE, Wallach MA (1998). "Dual diagnosis: a review of etiological theories". Addictive Behaviors 23 (6): 717–34. doi:10.1016/S0306-4603(98)00073-2. PMID 9801712. 
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Library of Congress, Producer, Sciacca Comprehensive Service Development for MIDAA, NY, NY.

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