Dual Diagnosis Dr. Mohammad Hussein August 2018

1. Dual Diagnosis

2. Roadmap

3. The Dual Diagnosis
Dilemma

4. The Dual Diagnosis Dilemma
D.D
The Eyes
Don't See
What the
Mind Don't
Know
The Role
The majority
of patients
are dual
diagnosis

5. Dual Diagnosis Definition
Dual diagnosis is a term for when
someone experiences a mental illness
and a substance use disorder
simultaneously.
Either disorder—substance use or
mental illness—can develop first

6. Dual Diagnosis Synonyms
Co-morbid disorders
Co-occurring disorders
Concurrent disorders
Co-morbidity
Dual disorders
Dual diagnosis
Double-Trouble

7. Dual Diagnosis in numbers
Of SUDs
Have current
or past
mental
illness
Greater than
50%
Greater than
50%
Of
Psychiatric
patients
Have current
or past of
SUD
60%
Of alcohol
treatment
Have Psychiatric
Syndrome
40%
Of Drug
treatment have
Psychiatric
Syndrome

8. Severity

9. Severity ASI
0
5
10
15
20
25
Medical Employment Family Social Psychological Substance Use
Addiction Dual diagnosis
*
*
* * * *

10. Primary Substance of Abuse
0%
10%
20%
30%
40%
Alcohol Cocaine Heroin Crack Marijuana Meth
Addiction Dual diagnosis

11. Length of Stay in Treatment
0
10
20
30
40
50
60
70
80
90
100
Addiction Dual diagnosis
57.2 Days
86.8 Days
*

12. Discharge Characteristics
0%
20%
40%
60%
80%
100%
Completed Treatment Abstinent Past 30 Days
Addiction Dual diagnosis
*
*

13. Dual Diagnosis is
Psychiatry
Mental health professionals may
believe that substance abuse is
a symptom of mental illness
Addiction
Addiction professionals may
believe that mental illness is a
symptom or manifestation of
substance abuse

14. Dual Diagnosis & Suicide
Psychoactive drugs are present at autopsy in 30–50% of suicides
Disinhibition
deepening mood or worsening psychosis
Providing Courage
clouding Judgment and the ability to
see alternatives
01
02
03
04

15. Types
of Dual Diagnosis
Patients

16. Types of Dual Diagnosis Patients
 Axis I diagnosis of a major
psychiatric disorder, such as
schizophrenia
 require medication to control their
psychiatric illness
 Substance abuse may exacerbate
acute psychiatric symptoms
 exhibit the residual effects
mentally ill
chemically dependent
 severe substance dependence
 require treatment in alcohol or drug
treatment programs.
 coexistent personality disorders
 Do not exhibit the residual effects
chemical abusing
mentally ill

17. Relation between
Mental Disorders
& Substance Use Disorders

18. Relation between Mental Disorders
& Substance Use Disorders
01
03
04 02
05
PROVOKE
PSYCHIATRIC
DISORDERS
EXACERBATE
PSYCHIATRIC
DISORDERS
MASK PSYCHIATRIC
SYMPTOMS AND
DISORDERS.
MIMIC
PSYCHIATRIC
DISORDERS
SUBSTANCE
WITHDRAWAL CAN
CAUSE PSYCHIATRIC
SYMPTOMS
SUDs

19. Relation between Mental Disorders
& Substance Use Disorders
BEHAVIORS CAN MIMIC BEHAVIORS ASSOCIATED
WITH SUBSTANCE USE PROBLEMS
PROMPT SUBSTANCE USE DISORDERS.
03
02
01
PSYCHIATRIC
DISORDERS
EXACERBATE SUBSTANCE USE DISORDERS.

20. Time Frames for Symptom Abatement
with Abstinence
DEPRESSION AND ANXIETY DUE TO ALCOHOL DEPENDENCE:
4–6 WEEKS (MAYBE LONGER)
PSYCHOSIS DUE TO AMPHETAMINES AND/OR CANNABIS:
7–10 DAYS
PROLONGED SYMPTOMS BEYOND THESE PERIODS SUGGEST
AN UNDERLYING MENTAL HEALTH PROBLEM

21. Majority of alcoholics are depressed
Significant associations between substance use disorders and major depression
have also been found in general population
Self medication theory
Depressed patients among substance use more likely to ask help
Depression & Substance Use Disorders

22. Anxiety & Substance Use Disorders
25 – 45 %
of alcohol
abuse and
dependence
suffer from
anxiety
disorders
15 – 25 %
of anxiety
patients suffer
from
Substance Use
Disorders
30 %
of patients
presenting
with panic
disorder have
reported an
onset
associated
with illicit
drug use
Hyperventilat-
ion and other
symptoms
associated
with
withdrawal
from alcohol
have also been
reported to
trigger long-
lasting panic
disorder

23. ADHD & Substance Use Disorders
15% OF ADULT ADHD  SUD
5% OF ADULT NON-ADHD  SUD
Early work reported that individuals with co-occurring ADHD had:
– Earlier onset of substance use
– More severe course of SUD
– Poorer treatment adherence Dopamine Theory
of ADHD

24. Schizophrenia & Substance Use Disorders
IN SCHIZ INCREASE SUDS
IN SUD  INCREASE SYCHOSIS
POOR COMPLIANCE & PROGNOSIS
INCREASE RISK OF SUICIDE &HOMICIDE

25. Personality Disorders
& Substance Use Disorders
Antisocial PD
Narcissistic PD
2
3
Borderline PD
1

26. Personality Disorders
& Substance Use Disorders
 To diminish symptoms of the disorder.
 To enhance low self-esteem.
 To decrease feelings of guilt.
Self harm  risky dosing
Take care of BNZ
Borderline PD
1

27. Personality Disorders
& Substance Use Disorders
 extreme antisocial symptoms
prefer stimulants
 less severe antisocial personality
disorder may use heroin and
alcohol to diminish feelings of
depression and rage
Antisocial PD

28. Personality Disorders
& Substance Use Disorders
 Aim to hide personal deficit
 BNZ, Alcohol, Cannabis
 Stimulants  grandeur
 Steroids to build up a sense of physical
perfection

29. Assessment of Patients
with Dual Diagnosis

30. Retrospective methods
Assessment of Patients with Dual Diagnosis
01
02
03
04
05
Asking the subject to report on past substance use over
designated time interval
Addiction Severity Index (ASI)
Time Line Follow-back interview (TLFB)
Retrospective self-report is practical for most
settings and is the most frequently used
The potential for memory failure or other sources of
distortion.

31. Objective indicators
Assessment of Patients with Dual Diagnosis
01
02
03
04
05
Blood-or urine-based drug screens.
Gamma-glutamyl transpeptidase.
Mean corpuscular volume.
Collateral reports

32. Assess Risk
Assessment of Patients with Dual Diagnosis
01 Assessment of dangerousness for self and/or others
including intent
02 History of previous violent behavior or suicidal attempts.
03 Medical assessment.
04 Social assessment.
05 family history of mental health problems

33. Building Rapport
Assessment of Patients with Dual Diagnosis
04
Conduct substance use assessment after assessing
other areas of life functioning and history
Use non-judgmental interviewers
Use simple, direct questions and clearly
defined timeframes
Use open-ended questions
and normalize substance use
01
02
03
04

34. Treatment

35. Treatment System Paradigms
1 2
3 4
Independent,
disconnected
Sequential,
disconnected
Parallel,
connected
Integrated

36. Stages of Treatment
01 Engagement
02 Persuasion
03 Active Treatment
04 Relapse Prevention

37. Stages of Treatment
01 Engagement
 Establish a working alliance with the client
Just keep coming back

38. Stages of Treatment
02 Persuasion
 awareness that substance use is a problem and
increase their motivation to change
 Motivational Interviewing
 Peer Groups (persuasion groups)
 Social skills training

39. Stages of Treatment
03 Active Treatment
help the client attain abstinence
 Social skills training to address substance-
related situations
 Peer groups (active treatment groups)
 Self-help groups (12 step,)
 Individual Cognitive-Behavioral counseling
 Psycho-education
 Stress management and coping skills
 Family and individual problem solving

40. Stages of Treatment
04 Relapse Prevention
maintain awareness that relapse can happen in order
to prevent it and to extend recovery to other areas
(social relationships, work…)
 Expanding involvement in supported or
independent employment
 Groups (active treatment or relapse prevention,
12-step,)
 Social skills training
 Family problem solving
 Lifestyle improvements (smoking cessation, diet,

41. Each disorder should be considered
primary, and integrated dual primary
treatment is recommended

42. Hierarchy of Recovery
PHASE 4: Recovery & Rehabilitation
Continued sobriety and stability
One year - ongoing
PHASE 3: Prolonged Stabilization
Active treatment,
Maintenance,
Relapse Prevention
PHASE 1: Stabilization
Stabilization of active substance
use or acute psychiatric
symptoms
PHASE 2: Engagement
Motivational Enhancement
Contemplation, Preparation,
Persuasion

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@nafsyclinic
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