Establishing an accurate diagnosis for individuals in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must distinguish between acute primary psychiatric disorders and psychiatric symptoms that are caused by the abuse of drugs or alcohol. To do so, clinicians must obtain a thorough history of alcohol and drug use as well as psychiatric symptoms and disorders.
Dual diagnosis is a term that is used to describe the presence of a coexisting substance use disorder and mental health disorder. There are several possible relationships that can exist between mental health disorders and drug or alcohol use. The use of drugs and/or alcohol can induce, worsen, or diminish symptoms of mental health disorders, which can, in the end, make the process of accurately diagnosing a disorder much more complicated.
The primary relationships between drug and/or alcohol use and mental health symptoms or disorders are described in the following:
- Drug and/or alcohol use can cause the onset of mental illness symptoms and can mimic mental health disorders. Acute and chronic substance use can elicit symptoms associated with almost any mental health disorder. The type, severity, and duration of these symptoms are usually related to the specific dynamics of the substance abuse (i.e. the type, severity, and duration of the substance use itself).
- Acute and chronic substance abuse can prompt the development, provoke the reemergence, or worsen the severity of mental health disorders.
- The abuse of substances has the potential to mask the symptoms of mental health disorders. Some individuals may use drugs and/or alcohol to alleviate the distressing symptoms of mental illness or to ameliorate the unpleasant side effects of certain medications that may have been used to treat the symptoms of mental illness.
- Going through drug or alcohol withdrawal can induce symptoms of mental illness or mimic mental health disorders. Withdrawal occurs when a person has developed a tolerance to or dependence on a substance and then suddenly ceases that use. As the body attempts to readjust to functioning without the presence of the substance(s), unpleasant withdrawal symptoms can occur.
- Mental health disorders and substance use disorders can coexist. One disorder may prompt the emergence of the other, or each disorder may exist independently. Determining whether the disorders are related (in that one caused the onset of the other) can be difficult, yet may not be of great significance when an individual has been suffering from both. For example, if an individual has bipolar disorder and developed a dependence on alcohol years prior, yet still experiences the symptoms of bipolar disorder along with a dependence to alcohol many years later, he or she has two well-developed disorders, and both disorders require treatment.
- Mental illness behaviors can mimic behaviors associated with substance use disorders. Maladaptive and dysfunctional behaviors that are consistent with drug and/or alcohol abuse may actually have other causes, such as emotional, social, or psychiatric problems.
When individuals are suffering from a combination of a mental health disorder and a substance use disorder, and they are unable to overcome their substance abuse, it can be extremely difficult (if not impossible) to fully recover from the symptoms of the mental illness. The symptoms of the mental health disorder may impair the individual’s ability and motivation to participate in addiction treatment. Or, vice versa, the presence of the substance use disorder may prohibit his or her ability to comply with the treatment guidelines that are designed to heal the mental illness symptoms. When such is the case, the ability to overcome one may be misinterpreted as signs of treatment resistance or substance use relapse, both of which can significantly hinder the recovery process.
As was previously mentioned, dual diagnosis is a term used to define the coexistence of a mental health disorder and a substance use disorder. For example, a cocaine addiction may exist alongside bipolar disorder, an alcohol addiction may co-occur with major depressive disorder, a heroin addiction may coexist with schizophrenia, or an addiction to prescription painkillers may present in combination with borderline personality disorder. However, these are only a few examples. Any combination of a substance use disorder(s) that co-occurs with a mental health disorder(s) is considered dual diagnosis and must be treated as such. In other words, the symptoms of both disorders must be addressed in order for true healing to occur.
Unfortunately, individuals who are suffering from mental illness are at a greater risk for suffering from substance use disorders. Additionally, these individuals are increasingly susceptible to experiencing more severe and chronic medical, emotional, and social problems. Because they are battling more than one disorder, they are consistently vulnerable to both addiction relapse and/or the worsening of their mental illness symptoms. Furthermore, addiction relapse can lead to the deterioration of mental health and, conversely, the worsening of mental illness symptoms can lead to a relapse in drug and/or alcohol abuse. When compared with individuals who are suffering from a single disorder, those with dual diagnosis frequently require longer treatment, experience more crises, and progress more gradually while in treatment.
The Terminology of Dual Disorders
The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders. Recently, within the fields of mental health, psychiatry, and addiction medicine, the term has been popularly used to describe the coexistence of a mental health disorder and AOD problems. The equivalent phrase dual disorders also denotes the coexistence of two independent (but invariably interactive) disorders, and is the preferred term used in this Treatment Improvement Protocol (TIP).
The acronym MICA, which represents the phrase mentally ill chemical abusers, is occasionally used to designate people who have an AOD disorder and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. A preferred definition is mentally ill chemically affected people, since the word affected better describes their condition and is not pejorative. Other acronyms are also used: MISA (mentally ill substance abusers), CAMI (chemical abuse and mental illness), and SAMI (substance abuse and mental illness).
Common examples of dual disorders include the combinations of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Although the focus of this volume is on dual disorders, some patients have more than two disorders, such as cocaine addiction, personality disorder, and AIDS. The principles that apply to dual disorders generally apply also to multiple disorders.
The combinations of AOD problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.
Thus, there is no single combination of dual disorders; in fact, there is great variability among them. However, patients with similar combinations of dual disorders are often encountered in certain treatment settings. For instance, some methadone treatment programs treat a high percentage of opiate-addicted patients with personality disorders. Patients with schizophrenia and alcohol addiction are frequently encountered in psychiatric units, mental health centers, and programs that provide treatment to homeless patients.
Patients with mental disorders have an increased risk for AOD disorders, and patients with AOD disorders have an increased risk for mental disorders. For example, about one-third of patients who have a psychiatric disorder also experience AOD abuse at some point (Regier et al., 1990), which is about twice the rate among people without psychiatric disorders. Also, more than half of the people who use or abuse AODs have experienced psychiatric symptoms significant enough to fulfill diagnostic criteria for a psychiatric disorder (Regier et al., 1990; Ross et al., 1988), although many of these symptoms may be AOD related and might not represent an independent condition.
Compared with patients who have a mental health disorder or an AOD use problem alone, patients with dual disorders often experience more severe and chronic medical, social, and emotional problems. Because they have two disorders, they are vulnerable to both AOD relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric decompensation, and worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specially designed for patients with dual disorders. Compared with patients who have a single disorder, patients with dual disorders often require longer treatment, have more crises, and progress more gradually in treatment.
Psychiatric disorders most prevalent among dually diagnosed patients include mood disorders, anxiety disorders, personality disorders, and psychotic disorders. Each of these clusters of disorders and symptoms is dealt with in more detail in separate chapters.
AOD Abuse, Addiction, Dependence, Misuse
The characteristic feature of AOD abuse is the presence of dysfunction related to the person’s AOD use. The Diagnostic and Statistical Manual of Mental Disorders(DSM-III-R), produced by the American Psychiatric Association and updated periodically, is used throughout the medical and mental health fields for diagnosing psychiatric and AOD use disorders. It provides clinicians with a common language for communicating about these disorders and for making clinical decisions based on current knowledge. For each diagnosis, the manual lists symptom criteria, a minimum number of which must be met before a definitive diagnosis can be given to a patient.
Criteria for AOD abuse hinge on the individual’s continued use of a drug despite his or her knowledge of “persistent or recurrent social, occupational, psychologic, or physical problems caused or exacerbated by the use of the [drug]” (American Psychiatric Association, 1987). Alternately, there can be “recurrent use in situations in which use is physically hazardous.” The DSM-IV draft continues this emphasis (American Psychiatric Association, 1993).
Thus, AOD abuse is defined as the use of a psychoactive drug to such an extent that its effects seriously interfere with health or occupational and social functioning. AOD abuse may or may not involve physiologic dependence or tolerance. Importantly, evidence of physiologic dependence and tolerance is not sufficient for diagnosis of AOD abuse. For example, use of AODs in weekend binge patterns may not involve physiologic dependence, although it has adverse effects on a person’s life.
- Significant impairment or distress resulting from use
- Failure to fulfill roles at work, home, or school
- Persistent use in physically hazardous situations
- Recurrent legal problems related to use
- Continued use despite interpersonal problems
Therefore, screening questions should relate to life problems that result from AOD use, taking into consideration that patients may not have the insight to perceive that their life problems are caused by AOD abuse.
The phrase AOD addiction (called “psychoactive substance dependence” in the DSM-III-R and “substance dependence” in the DSM-IV draft) is an often progressive process that typically includes the following aspects: 1) compulsion to acquire and use AODs and preoccupation with their acquisition and use, 2) loss of control over AOD use or AOD-induced behavior, 3) continued AOD use despite adverse consequences, 4) a tendency toward relapse following periods of abstinence, and 5) tolerance and/or withdrawal symptoms.
AOD Addiction or Dependence
- Pathologic, often progressive and chronic process
- Compulsion and preoccupation with obtaining a drug or drugs
- Loss of control over use or AOD-induced behavior
- Continued use despite adverse consequences
- Tendency for relapse after period of abstinence
- Increased tolerance and characteristic withdrawal (but not necessary or sufficient for diagnosis)
The DSM-III-R describes nine diagnostic criteria, of which three or more must be present for a month or more to establish a diagnosis of dependence. Screening questions can be based on these criteria. The DSM-IV draft committee deleted DSM-III-R criterion 4 and the requirement of symptoms being present for at least 1 month. The DSM-IV draft emphasizes the symptoms of tolerance and withdrawal, which the draft committee placed at the top of the list of criteria.
In the DSM-III-R, criteria 1 and 2 deal with loss of control; criterion 3 addresses time involvement; criteria 4 and 5 relate to social dysfunction; criterion 6 relates to continued use despite adverse consequences;and criteria 7, 8, and 9 relate to the development of tolerance and withdrawal. It is important to note that tolerance, physiologic dependence, and withdrawal are neither necessary nor sufficient for the establishment of a diagnosis of AOD addiction.
The term AOD dependence can be confusing because it has multiple meanings. The DSM-III-R uses the phrase “psychoactive substance dependence” to describe the process of addiction, while many pharmacologists use the term “dependence” exclusively for describing the biologic aspects of physical tolerance and/or withdrawal. The American Society of Addiction Medicine describes drug dependence as having two possible components: 1) psychologic dependence and 2) physical dependence.
Psychologic dependence centers on the user’s need of a drug to reach a level of functioning or feeling of well-being. Because this term is particularly subjective and almost impossible to quantify, it is of limited usefulness in making a diagnosis.
Physical dependence refers to the issues of physiologic dependence, establishment of tolerance, and evidence of an abstinence syndrome or withdrawal upon cessation of AOD use. In this case, AOD type, volume, and chronicity are the important variables: Given a certain substance, the higher the dose and longer the period of consumption, the more likely is the development of tolerance, dependence, and subsequent withdrawal symptoms. Physical dependence and tolerance are best understood as two of many possible consequences (which may or may not include addiction and abuse) of chronic exposure to psychoactive substances.
Among patients with a psychiatric problem, any AOD use — whether abuse or not — can have adverse consequences. This is especially true for patients with severe psychiatric disorders and patients who are taking prescribed medications for psychiatric disorders. For patients with psychiatric disorders, the infrequent consumption of alcohol can lead to serious problems such as adverse medication interactions, decreased medication compliance, and AOD abuse. Screening questions can relate to evidence of any use of AODs, as well as frequency, dose, and duration.
Medication misuse describes the use of prescription medications outside of medical supervision or in a manner inconsistent with medical advice. While medication misuse is not an abuse problem per se, it is a high-risk behavior that: 1) may or may not involve AOD abuse, 2) may or may not lead to AOD abuse, 3) may represent medication noncompliance and promote the reemergence of psychiatric symptoms, and 4) may cause toxic effects and psychiatric symptoms if it involves overdose.
Thus, some patients may consume medications at higher or lower doses than recommended or in combination with AODs. Also, certain patients may respond to prescribed psychoactive medications by developing compulsive use and loss of control over their use.
Treatment for Dual Diagnosis: Substance Abuse and Mental Illness
People who have both a mental or emotional disorder and a drug or alcohol addiction are said to have a dual diagnosis disorder. A dual diagnosis disorder is very common and it’s also very treatable. For the best chance of recovery, people with a dual diagnosis need integrated treatment for both substance abuse and their mental or emotional disorder at the same time.
How Common Is a Dual Diagnosis?
- More than half of all people with a serious mental illness also have an alcohol or drug abuse or addiction problem, according to the Substance Abuse and Mental Health Services Administration.
- More than fifty percent of drug abusers and 37 percent of alcohol abusers have a mental illness, according to the Journal of the American Medical Association.
Why Is Integrated Treatment so Important?
Each condition worsens and can prompt the other:
- Alcohol and drugs can worsen psychiatric symptoms, reduce the effectiveness of psychiatric medications and reduce the likelihood of treatment compliance.
- Symptomatic mental illness can prompt the use of alcohol or drugs as self medication, and can reduce the resolve or ability to stay abstinent.
For a better chance at lasting recovery, treatment must address both problems at the same time — and, ideally, should be from the same team of doctors, therapists and healthcare professionals.
Effective Dual Diagnosis Treatment
The first step in dual diagnosis treatment, if needed, is medical detoxification, which focuses primarily on the addiction. After successfully withdrawing from drugs or alcohol, the client can then participate in more integrated treatment for both addiction and mental illness.
Some components of effective dual diagnosis treatment programs include the following:
- Programs that are developed exclusively for the treatment of dual diagnosis patients and that offer group therapy sessions comprised of patients undergoing similar challenges.
- Programs that offer case management services, ensuring that the therapeutic services of a team of clinicians are delivered in an integrated manner and with full cooperation and communication between all involved.
- Programs that bring in family members for support, education and involvement in the recovery process.
- Programs that offer life-skills training, education or employment assistance programs.
- Programs staffed by doctors able and willing to prescribe medications as appropriate.
Recovery From a Dual Diagnosis is Very Possible
A dual diagnosis can complicate the situation, treatment can take longer and dual diagnosis patients should seek out care specific to their needs — but dual diagnosis treatment can and does work.