Dual Diagnosis

by Rethink

Introduction

Dual diagnosis is the co-occurence of mental health problems and substance misuse (alcohol an/or drug dependence). Thirty-seven percent of alcohol abusers and 53% of drug abusers also have at least one serious mental illness.

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.

The following psychiatric problems are common to occur in dual diagnosis:

• Depressive disorder, such as depression and bipolar disorder
• Anxiety disorders, including generalised anxiety disorder, panic disorder, obsessive-compulsive disorder and phobias.
• Other psychiatric disorders, such as schizophrenia and personality disorders.

Having a mental disorder significantly increases your risk of misusing alcohol and drugs. Of all people diagnosed as mentally ill, 29% either abuse alcohol or drugs. The following table taken from a National Institute of Mental Health study lists sever major psychiatric disorders and shows how much each on increases an individual's risk for substance abuse.

Psychiatric disorder	Increased risk of substance abuse
Antisocial personality disorder	15.5%
Manic episode	14.5%
Schizophrenia	10.1%
Panic disorder	4.3%
Majpor depressive episode	4.1%
Obsessive-compulsive disorder	3.4%
Phobias	2.4%

Therefore, someone suffering from schizophrenia is at a 10.1% higher-than-average risk of being an alcoholic or drug abuser.

People with these disorders are frequently seen within mental health services but are often found outside these systems of care, often among the homeless, and within the criminal justice system.

which problem develops first?

It can be difficult to tell which problem came first. Often the psychiatric problem develops first and in an attempt to feel calmer, more alive, or more cheerful, a person with psychiatric syptoms may drink or use drugs. Doctors call this "self-medication". Frequent self-medication may eventually lead to physical and psychological dependency on alcohol or drugs. If this does, the person then suffers from not just one problem, but two.

In other cases, alcohol or drug dependency is the first condition to develop. A person whose substance abuse problem has become severe may develop symptoms of a psychiatric disorder.

What Are The Symptoms Of Dual Diagnosis?

Both illnesses experienced by a person with dual diagnosis affect an individual physically, psychologically, socially and spiritually. Each illness has symptoms that interfere with a person's ability to function effectively and relate to themselves and others. Not only is an individual affected by the symptoms of two separate illnesses, the symptoms from each interact with one another. The illnesses may exacerbate each other and each disorder makes relapse more likely in the other illness. At times symptoms can overlap and even mask each other making diagnosis and treatment more difficult. The diagnosis of a mental health problem must be made by a doctor or psychiatrist. It is important that if you suspect someone you know has a drug or alcohol problems and is showing signs of mental illness or someone with a mental illness is abusing drugs and/or alcohol that you talk to them about getting a mental health assessment or a review.

signs and symptoms of substance abuse

Some of the signs and symptoms of substance abuse are:

• Abrupt changes in work or school attendance, quality of work, work output, grades, discipline.
• Unusual flare-ups or outbreaks of temper.
• Withdrawal from responsibility.
• General changes in overall attitude.
• Deterioration of physical appearance and grooming.
• Association with known substance abusers.
• Unusual borrowing of money from friends, co-workers or parents.
• Stealing small items from employer, home or school.

symptoms of mental illness

Different mental illnesses have different symptoms. You can read more about the symtoms of the following mental illnesses:

• schizophrenia
• schizoaffective disorder
• bipolar disorder
• depression
• personality disorders
• anxiety disorders
• eating disorders

It is important to note that the symptoms of mental illness in someone who has a drug or alcohol problem may vary from someone with a mental illness alone.

Other problems and consequences that are associated with dual diagnosis include:

• Family problems or problems in intimate relationships.
• Isolation and social withdrawal.
• Financial problems.
• Employment or school problems.
• High risk behavour while driving.
• Multiple admission for chemical dependenccy 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.

What Are The Causes Of Dual Diagnosis?

Mental health and addiction professionals increasingly believe that brain disorders and substance abuse disorders are biologically based. Because having a substance abuse disorder increases your risk of developing a mental disorder and vice versa it is important to look at the causes of each as well as each being a cause of the other.

causes of substance abuse

People start taking drugs for a number of reasons. They may include:

• Just curious
• Sense of adventure
• Enjoyment
• Belief that the drug helps physical or mental performance
• Belief that the drug is harmless
• Belief that the drug will help stress, depression or other symptoms of mental illness
• To cope with trauma e.g. child sex abuse, school failure, or relationship problems
• Sensations seeking
• Drug use by other family members
• Peer pressure - influenced by peer selection. for example, most youths who smoke tobacco are making conscious decisions to be with a peer group dominated by smokers.
• Rebellion against authority/parents
• Postivie images in the media
• Access, availablity and relatively low cost

Many people continue to take drugs often because they like what the drugs do to their brains, and the effect they get.

However there are a number of factors which turn someone experimenting with drugs into an addict. Current research is looking into the nature of addiction and why some people become addicts while others do not. There is strong evidence for a genetic influence on the risk of addiction. It seems that some brains are particularly prone to addictive patterns. sons of alcoholic fathers who are brought up by sober foster parents are eight times more likely to become alcoholics than their fostered siblings born of a non-alcoholic fater. As many as seven out of ten alcoholics may carry the dopamine D2 receptor A1 gene, compared to one in five of the general population.

As well as genetic predispositions to drug and alcohol addiction there are other risk factors with people developing an addiction. These include:

• A family member with a drug or alcohol addiction.
Children who are alcoholics or drug users are at a greater risk of developing a substance use disorder than those without such a history. Having an alcoholic family member, for example, doubles the risk of a male child later becoming alcohol or drug dependent.
• People with family history of criminality or anti-social behaviour are more likely to use drugs and alcohol than those without such a history.
• Inconsistent parental direction or discipline, unclear or inconsistent parental rules and reactions to children's behaviour, unusual permissiveness, lax supervision, or conversely, excessive severe discipine, constant critisism, and an absence of parental praise or approval are all associated with higher rathes of alcohol and drug use.
• Children who are poor academic achievers are more likely to begin using drugs early, and to become rgualr drinkers and drug users than are their more sucessful classmates.
• The earlier a person begins to smoke, drink, or use other drugs, the greater the likelihood of heavy drug use.
• Early antisocial behaviour, evidence of a lack of social responsibility, fighting and other types f aggressive behaviour are predictive of later alcohol and other drug use.
• People with an active role in religion are less likely to use drugs and alcohol.
• Substance misuse reaches people from all socioeconomic backgrounds but is more likely among people suffering from poverty.

causes of mental health problems

In the case of dual diagnosis the substance misuse may have triggered or caused the mental health problem, however, the mental health problem may have developed first. Causes of different mental health problems can be found on the following links:

• schizophrenia
• schizoaffective disorder
• bipolar disorder
• depression
• personality disorder
• anxiety disorders
• eating disorders

How Can Dual Diagnosis Be Treated? Mortality Rates

Increasingly, psychiatists and drug counsellors agree that both disorders must be treated at the same time. Early studies show that when mental illness and substance abuse are treated together, suicide attempts and psychotic episodes decrease rapidly.

Treatment of people with dual diagnosis can be difficult because typically they are difficult to engage, motivate and have poor medication compliance. In addition social factors such as lack of housing or access to benefits also prevent successful treatment. In this way, an integrated approach to treatment has been found to be most successful.

1. Initially, the mental health team will make contact with the person, show them what it has to offer, provide social support, and involve carers and family if appropriate.

2. When an initial relationship has formed, mental health workers work to help clients understand the nature of their problems and what can be done about it. At the same time specific counselling skills can be used to help motivate the person into making change.

3. Active treatment combines medication to treat the mental illness, education, family involvement and cognitive-behavour therapy. Two important factors to the success of treatment are the development new coping skills and a social network.

4. The final step of treatment is the prevention of relapse. The person is taught to identify situations in which they will become vulnerable to substance misuse and how to deal with these situations.

Mortality rates

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 transistion 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.

About the Author

www.rethink.org
Rethink is the largest severe mental illness charity in the UK. We are dedicated to improving the lives of everyone affected by severe mental illness, whether they have a condition themselves, care for others who do, or are professionals or volunteers working in the mental health field.