25. dual diagnosis - substance abuse and psychiatric illness

8/12/2019 25. Dual Diagnosis - Substance Abuse and Psychiatric Illness

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8 Dual Diagnosis: Substance Abuse and Psychiatric IllnessBIBLIOGRAPHY

I . Crowley TJ: Learning a nd unlearning abu se in the real world: C linical treatment and public policy. NIDAResearch Monograph No. 84. Washington, DC,U S . Government Printing Office, 1988,pp 100-121.2. Clayton RR, Voss HL: Young men and drug s in Manhattan: A causal analysis. NIDA R esearch MonographNo. 9. W ashington,DC S . Government Printing Office, 1981.3 . Dinwiddie SH:Abuse of inhalants: A review. Addiction 89:925-939, 1994.4. Li 5 Stokes SA Woeckener A: A tale of novel intoxication: A review of the effects of y-hydroxybutyric acid5 Millrnan RB , Sb riglio R: Patterns of use and psychopathology in chronic marijuana users. Psychiatr Clin6 . Schutz CG , Chilcoat H D, Anthony JC : The association between sniffing inhalants and injecting drugs. Compr7. Solowij N: Ecstasy 3,4-methylenedioxymethamphetarnine). Cum Opin Psychiatry 6:41 I 4 1 , 1993.8. Steele TD, McCann UD, Ricaurte GA: 3,4-MethylenedioxymethamphetamineMDMA, Ecstasy):

with recommendations fo r management. Ann Emerg Med 3 1:729-736, 1998.North Am 9533 -545 , 1986.Psychiatry 35:99-105, 1994.

Pharmacology and toxicology in animals and humans. Addiction 895 39-551, 1994.

25. DUAL DIAG NO SIS: SUBSTANCE ABUSEAND PSYCHIATRIC ILLNESSS. Tziporah Cohen,M. D. nd Alan M. aco6son,M. D

1. What is meant by the term dual diagnosis?It describes patients who have both a substance use disorder and another major psychiatric dis-order. Examples include a cocaine-dependent patient with panic disorder and an alcoholic patientwith major depression. The term is used to highlight the difference between such patients and pa-tients with a single diagnosis; patients with a dual diagnosis have special diagnosis and treatmentneeds. Although dual diagnosis refers to all patients with concomitant diagnoses of substance abuseand other psychiatric illness, the population is highly heterogeneous. Both of the patients mentionedabove, for example, have dual diagnoses, but their disorders may require very different treatments.

2. Is dual diagnosis common?Yes. Dual diagnosis is extremely common and often unrecognized. Of patients with a substanceuse disorder, approximately 50 have at least one other psychiatric disorder, most commonly amood or anxiety disorder. Conversely, almost 30 of patients with other psychiatric disorders alsohave a history of substance abuse.3. Why is it important to determine whether a patient has both a substance use and another

psychiatric disorder?The importance of identifying substance abuse in a patient with a psychiatric disorder cannot beoverstated. In general, patients with a dual diagnosis have higher morbidity, lower likelihood for ini-tial treatment success, higher relapse rates, increased rates of hospitalization, and decreased adher-ence to treatment. They also are at increased risk for suicide. The presence of substance abuse makesdiagnosis of both disorders more complicated. For treatment of either disorder to be successful, bothmust be identified and treated individually.4. Do certain psychiatric conditions tend to be seen with substance abuse?Yes. Antisocial personality disorder is highly correlated with substance abuse. In one extensivestudy, 84 of individuals with antisocial personality disorder also had a history of substance abuse.Mood disorders also are commonly associated with substance abuse; in the same study, 32 of indi-viduals with a diagnosis of mood disorder were substance abusers. In addition, specific psychiatric


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Dual Diagnosis: Su bsta nce Abuse an d Psychiatric Illness I9disorders are associated with spec i j k drugs of abuse, such as bipolar disorder with alcohol and panicdisorder with sedatives and hypnotics.5. What is the cause of dual diagnosis?

Many m echanisms have been proposed to explain the co-occurrence of a substance use disorderand an other psychiatric illness, but no evidence su ggests that any one mechanism is the only p ossi-ble explanation.Psychopathology may serve as a risk factor for addictive disorders or may affect the

course of an addictive disorder.For example, a 32-year-old woman with a severe social phobiafound that alcohol relieved her anxiety enough to allow her to function at her job. W ith repeated use,however, she became dependent on alcohol. Withdrawal symptom s led to more anxiety, which led tomore drinking, and eventually she developed full-blown alcohol addiction. A second example is a26-year-old male alcoholic with bipolar diso rder who had periods of abstin ence for as long as 6months. How ever, each time he entered a manic episode, he stopped going to Alcoholics Anonymousmeetings and began drinking again.There may be familial genetic) links between certain psychiatric disorders andsub-

stance use disorders. For example, a 40-year-old man w ith a history of alcoholism was diagnosedwith major depression . Family history showed that his mother had been dependent on alcohol in herearly thirties and had recently had a depressive episode. His m aternal grandmother also had a historyof depression. His m aternal uncle had been an alcoholic and comm itted suicide at age 38. Th e pa-tients sister had been diagnosed with major depression in college.Psychiatric symptoms may develop in the course of chronic intoxication with an abused

substance. For example, a 55-year-old man wh o had been sm oking marijuana almost daily for sev-eral years developed depressive sym ptoms as w ell as paranoid ideation. The symp toms disappearedwhen he stopped using marijuana.Psychiatric disorders may emerge as a consequence of substance use and persist after re-mission. For examp le, a 30-year-old wom an with no history of psychiatric illness began using co-caine. After almost a year of use, she began having occasional panic attacks when high. After severalmore months, the attacks occurred in between co caine highs. Years later, despite having been drug-free for 6 months, the panic attacks continued. They were successfully treated with paroxetine.The occurrence of both disorders in the same individual is pure coincidence. Becauseboth mental illness and substance abuse are highly prevalent in the general population, an individualmay have both a substance use disorder and a psychiatric disorder by chance, just as one individualmay have both asthma and migraine headaches.

6. What is the self-medication hypothesis?The self-medication hypothesis holds that sub stance abuse occurs when an individual attemptsto self-medicate his or her psychiatric sym ptoms. This hypothesis is based on a small group of drugabusers and has not been validated experimentally. The theory holds that patients d o not abu se drugsrandom ly; rather, they discover a drug that relieves painful feelings and thereby serves as a copingmechanism. Repetitive use of the drug as self-medication eventually may lead to dependence. Evenafter treatment of the psychiatric disorder, the addiction m ay persist and require indepen dent treat-ment. For example, a 24-year-old man, who describes himself as having been depressed all of hislife, tried heroin at a party and said that for the first time he felt relief from emotional distress. Soonhe was using h eroin daily and needed increasing am ounts to get the same relief.7. Can certain psychiatric symptoms be confused with intoxication or withdrawal symp-

toms?Absolutely. Many p sychiatric sym ptoms can be caused by substance use o r withdrawal. For ex-ample, depressive symptom s such as insomnia, decreased libido, anhedonia, and suicidality oftenare seen with chronic alcoholism and marijuana use and may be indistinguishable from a major de-pressive episode. Manic symptoms, such as euphoria, inflated self-esteem, and decreased need forsleep, may occur during cocaine intoxication.


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I20 Dual Diagnosis: Substan ce Abuse and Psychiatric IllnessPsychiutric Symptoms Associated with Substance Abuse

PSYCHIATRIC SYMPT OMS PSYCHIATRIC SYMPTO MSSUBSTANCE DURING INTOXICATION DURING WITHDRAWALAlcohol Anxiety, depression, sudden mood changes,

paranoia, suicidality,memory lossCocaineStimulants Mania, paranoia, nightmares

Mania, acute paranoid ideation, panic attacks

Inhalants Anxiety, persona lity changesCannabis Anxiety, paranoid ideation, suicidalityOpioids Panic reactions, lethargyDepressants Depression, anxiety, paranoia, psychosis

Hallucinations (delirium tremens,alcohol h allucinosis) anxiety,insomnia, psychomotor agitation

Depression, anhedonia, anxietyDysphoria, psychom otor retardation,irritability, guilt, suicidalityAnxiety, depressionDepressionInsomnia, irritability, psychomotoragitation

Hallucinogens Hallucinations, paranoia, depersonaliza tion, Flashbacks (may occur years after lastconfusion use)8. Can substance abuse cause mental illness?Yes. Substance abuse m ay induc e psychiatric disorders that persist even after d rug use is discon-tinued. For examp le, some cocaine a busers develop panic attacks. Initially the attacks occur solelyduring cocaine intoxication, but with time they may occu r between c oca ine highs and even persistafter complete cessation of dru g use. These attacks often can be treated successfully with SSR Is orother treatments for panic disorder. Certain hallucinogen s, such as lysergic acid diethylamide (LSD),

may cau se perceptual d isturbances o r visual hallucinations that continue for years after last use. Theterm posthallucinogen perceptual disorderhas been coined t o describe the occurrence of such dis-turbances, traditionally called flashbacks. Substance abuse also may exacerbate an other already pre-sent but un recognized psychiatric disorder. In this case the substance abuse does no t cause thedisorder, but rather makes it clinically apparent.9 How can I tell whether a patients psychiatric symptoms are caused by substance abuse?Timing, timing, timing It is crucial to assess mental illness only after a period of abstinence, sothat diagnosis is not confounded by drug intoxication mimicking psychiatric symptoms. How longthe drug-free period m ust last before an accurate psychiatric d iagnosis can be m ade depen ds on boththe drug and the suspected disorder. Generally it is recommended that the patient be drug-free for2 4 weeks. A good history, from both the patient and family members, is crucial to understandingthe clinical picture. A good h istory or prior familiarity w ith the patient also can help sort out confus-ing symptoms and m ake quicker diagnoses.

10. Do patients with a dual diagnosis need special treatment?Yes and no. Th e most important issue is the need to treat both disorders. Treatment that mini-mizes the importance of either diag nosis results in unnecessarily high rates of relapse . Patientsshould be educated about both diagn oses and how they interact.Several treatmen t settings and metho ds are available to treat the substance-abusing p sychiatricpatient. Inpatient hospitalizationmay take place in a dual-diagnosis treatment unit, a substanceabuse treatment unit, or a psychiatric treatment unit. Dual-diagnosis units are the ideal setting, butthey are not always available. Patients can be ade quately treated in other settings, provided that theclinicians involved in their care are knowledgeable about their special needs. Outpatient programsare becoming mo re comm on and m ay involve intensive treatment that includes medication manage-ment, support groups, psychotherapy, self-help groups, and social services.Generally, patients leaving inpatient treatment should continue treatment as outpatients, as absti-nence requires long-term m onitoring and support. Patients referred to outpatient programs from inpa-tient treatment are likely to stay in treatment longer than those patients who are referred as outpatients.


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Dual Diagnosis Substance Abuse and Psychiatric Illness 211. What is the role of psychotropic medications?

Pharmacotherapy is not only appropriate in certain patients with dual diagnoses; it often is nec-essary (as in some patients with psychiatric illness alone). While most medications are directed atthe coexisting psychiatric disorder, a few are directed at substance use disorder. Naltrexone hy-drochloride, an opioid antagonist, has been shown to decrease relapse rates in alcohol-dependent pa-tients by half as compared to placebo. Desipramine, a tricyclic antidepressant (TCA), has been usedto decrease cocaine cravings in some patients.12. What should be considered when prescribing medication for substance abusers?

Several issues require special attention. Many drugs of abuse interact with psychotropic medica-tions. Abused substances may increase or decrease the metabolism of certain medications via the induc-tion of hepatic enzymes or a change in plasma protein binding. They can lower or raise plasma levels,resulting in decreased efficacy or dangerous side effects. Such interactions must be considered whenprescribing medications for a substance-abusingpatient or a patient with substance-abusingpotential.

Certain medications, such as benzodiazepines, are addictive in and of themselves, and their po-tential for abuse in patients with substance abuse histories is increased. Although such medicationsare often necessary, clinicians should prescribe the least habit-forming option that is efficacious. Forexample, a patient with panic disorder may be treated with a TCA rather than an anxiolytic, whichhas a higher addictive potential.

Interactions Between Drugs o Abuse and P sychotropic M edicationsDRUG OF ABUSE THERAPEUTIC AGENT POSSIBLE INTERACTIONS

Alcohol

Barbiturates

Disulfiram(Antabuse)

MA0 inhibitorsTCAsAntipsychotics

AnticonvulsantsTCAsMA0 inhibitorsAntipsychoticsAnticonvulsants

Benzodiazepines Disul firam

OpiatesMA0 inhibitorsMA0 inhibitorsAntipsychoticsAnticonvulsants

Flushing, hypotension, nausea, tachycardia; fatalreactions

Dangerous, possibly fatal hypertension due toimpaired hepatic metabolism of tyramineAdditive CNS impairment

Increased CNS impairment on psychomotor skills,judgment, and behavior; increased risk ofakathisia and dystonia

Inductionof hepatic microsomal enzymes,reducing phenytoin levels; seizure risk

Reduced efficacy of tricyclics; may potentiaterespiratory depression

Inhibited barbiturate metabolism, prolongingintoxication

Induced hepatic microsomal enzymes may reducechlorpromazine levels

Valproic acid increases phenobarbital levels andtoxicity; induced hepatic microsomal enzymesmay reduce carbamazepine levels and result inunpredictable phenytoin levels

Enhanced benzodiazepine effects (oxazepam andlorazepam not affected)

Rare reports of edema with chlordiazepoxideMeperidine-severe excitation, diaphoresis,

rigidity, hyperihypotension, coma; deathMeperidine and chlorpromazine-hypotensionand excessive CNS depression

Propoxyphene increases carbamazepine levelswith risk of toxicity; methadone metabolismmay be increased by carbamazepine or pheny-toin, causing withdrawal

Tuhle continued on following p a g e


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I 2 2 D u a l D i a g n o s i s : Substance Abuse and P s y c h i a t r i c IllnessInteractions Between Drugs o Abuse and Psychotropic Medications Continued)

DRUG OF ABUSE THERAPEU TIC AGENT POSSIBLE INTERACTIONSStimulants M A 0 inhibi tors Hyperpyrexia, severe hypertension, death when

used wi th coca ine or amphetaminesCocaine and amphetamines may cause de lus ionsand ha llucinations of chronic psychoses tobreak through antipsychotics

Anti psychotics

M A 0 = monoamine oxidase, TCAs = tricyclic antidepressants, CN S = central nervous system.Adapted from Ga stfriend DR : Pharmacotherapy of psychiatric synd rom es with comorbid chemical dependence.J Addict Dis 12(3):155-170, 199 3; with permission.13 Is psychotherapy helpful in treating patients with a dual diagnosis?

P s y c h o t h e r a p y , p a r t i c u l a r l y s u p p o r t i v e - e x p r e s s i v e or c o g n i ti v e - b eh a v i o ra l m o d e l s , h a s b e e ns h o w n t o be useful in t rea t ing pa t i en t s wi th s ubs tance use disorders a nd psychia t r i c i l lness , a l thoughi t s e ff i cacy dep ends on t he spec i f i c p sych i a t ri c d i so r de r and t h e d r u g of abuse. Pa t i en ts w i t h com or -b i d m ood and anx i e t y d i so r de r s t end t o bene f i t f r om psycho the r apy more than pa t i en t s wi th person-a l i t y d i s o r d e r s . In g e n e r a l , p s y c h o t h e r a p y p ro v i d e s s u p p o r t f o r c o n t i n u e d a b s t in e n c e as w e l l asadhe r ence t o m ed i ca t i on r eg i m ens . I t a l so add r e s se s unde r l y i ng em ot i ona l s t a t es , such as depress ionor anxiety, that may cont r ibute to t he m a i n t enance of subs t ance abuse .14. What is the role of self-help groups, such as Alcoholics Anonymous or Narcotics Anonymous?

T w e l v e - s t e p groups s u c h a s A l c o h o l ic s A n o n y m o u s , C o c a i n e A n o n y m o u s , a n d N a r co t ic sA n o n y m o u s a r e k n o w n t o c o n t r i b u te s u c c e s s f u ll y t o t h e m a i n t e n a n c e of a b s t i n e n c e i n s u b s t a n c e -abus i ng pa ti en ts . Al t ho ugh t hey m ay be helpfu l for pa t i en ts wi t h d ua l d i agnoses , t hey d o no t add r e s si s s u e s s pe c if ic t o t h is p o p u l a t i o n , s u c h a s u s e o f p s y c h o t r o p i c m e d i c a t i o n s or di f f i cu l t i es in l iv ingwi th me nta l i l lness. Se l f -he lp gro up s espec ia l ly for pa t i en t s wi th a du a l d i agnos i s m ay be t t e r add r e sss u c h c o n c e r n s, b u t b e c a u s e of t h e h e t e r o g e n e i t y of t h e p o p u l a t i o n , p at ie n t s m a y n o t f e e l t h a t t h e yh a ve m u c h in c o m m o n w i t h o t h e r p a r t ic i p an t s. For so m e pa ti en ts , how eve r , such g r o ups a r e inva l u-ab l e t oo ls , and pa r ti c i pa ti on shou l d b e enco ur age d on an i nd i v i dua l ba s i s.

BIBLIOGRAPHY1 . Abraham HD, Aldridge AM: Adverse consequencesof lysergic acid diethylamide. Addiction 83: 1327-1 334 , 1993.2. Bell CM , Khantzian EJ: Drug use and add iction as self medication: A psyc hody nam ic perspective. In GoldMS, Slaby AE: Du al Diagnosis an d Substa nce Abuse. New York, Marcel Dekker, 1991, pp 185-203.3. Bogenschutz MP, Siegfreid SL: Factors affecting engag eme nt of dual dia gno sis patients in outpatient treat-

ment. Psychiatric Services 49:1350-1352, 1998.4. Cohen S T Substance abuse and m ental illness. In Friedm an L, et al: Sourcebook of S ubstance Abuse andAddiction. Baltimore, Williams Wilkins, 1996 .5 Dackis CA, Gold MS:Psychopathology resulting from substance abuse. In Gold MS, Slaby AE: DualDiagnosis and Sub stance Abuse. New York, Marcel Dekker, 199 pp 205-220.6. Giannini AJ, Collins GB: Su bstance abuse and thought disorders. In Gold M S, Slaby AE: Dual Diagnosisand Sub stance Abuse. New York, Marcel De fi er , 1991, pp 57-93.7. Khan tzian EJ: Th e self-medication hypothesis of addictive disorders: Focus on heroin and cocaine depen-dence. American Journal of Psychiatry 142:1259, 1985.8. Meyer RE: How to understand the relationship between psyc hopa tholog y and addictive disorders: An otherexample of the chicken and the egg . In Meyer RE : Psychopathology and Addictive Disorders, New York,Guilford Press, 198 6, pp 3-15.9. Mirin SM , Weiss RD, Griffin ML, Michael JL: Psychopathology in drug abusers and their families. Com prPsychiatry 32:36, 1991.10. Norris CR , Extein IL: Diagnosing dual d iagnosis patients. In G old MS, Slaby AE: Dual Diagnosis andSub stance Abuse. New York, Marcel Dekker, 19 91, pp 159-184.1. OConnell DF: Dual Disorders-Essentials for Assessment and Treatment. New York, Haworth Press, 1998.12. Reiger DA, Farmer M E, Rae D S, et al: Comorbidity of mental diso rders with alcohol and other drug abuse:

13. Slaby AE: Du al diagnosis: Fact or fiction? In G old MS , Slaby AE: Dual Diagnosis and Substance Abuse.Results from the epide miolo gic catchment area study. JAMA 264:2 511, 1990.New York, Marcel D ef ier , 1991 pp 3-27.


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Dissociative Disorders I2314. Weiss RD, Mirin SM: The dual diagnosis alcoholic: Evaluation and treatment. Psychiatrhn 19:261-265, 1989.15. Weiss RD, Collins DA. Substance abuse and psychiatric illness.Am J Addict :93 1992.16. Weiss RD, Mirin SM Frances RJ: The myth of the typical dual-diagnosis patient. Hosp CommunityPsychiatry 43:107, 1992.

26. DISSOCIATIVE D ISORD ER S INCLUDINGDISSOCIATIVE IDENTITY DISORDER(FORMERLY MULTIPLE PERSONALITY DISORD ER )o h . K l u c k M.D.

1. What is dissociation?Dissociation is a defense mechanism whereby some elements of the conscious experience are dis-

connected from other elements of the conscious experience.For instance, during a severe trauma, a personmay dissociate the observing se lf from the experiencing self, as if they were watching anotherperson experience the trauma. As such, the observing self may not experience fear, horror, or pain.2 What are the dissociative disorders?

Dissociative disorders are a spectrum of disorders that rely heavily on dissociation as a means ofself-protection from extreme emotions. This coping mechanism leads to significant distress or im-pairment in social, occupational, or other important areas of functioning.3. What are the specific dissociative disorders, and how are they characterized?

Dissociative amnesia formerly psychogenic amnesia) is characterized by an inability torecall important personal information (usually of a traumatic or stressful nature), and the lack ofmemory is too extensive to be explained by ordinary forgetfulness.

Dissociative fugue formerly psychogenic fugue) is characterized by sudden and unexpectedtravel away from home or ones customary place of work, accompanied by an inability to recallones past and confusion about personal identity, or the assumption of a new identity.

Dissociative identity disorder formerly multiple personality disorder)is characterized bythe presence of two or more distinct identities or personality states that recurrently take control ofthe individuals behavior and are accompanied by an inability to recall important personal informa-tion. Individuals with this disorder experience frequent gaps in memory-losing time for personalhistory, both recent and remote.

Depersonalization disorder is characterized by a persistent or recurrent feeling of being de-tached from ones mental processes or body. It is accompanied by intact reality testing.

Dissociative disorder not otherwise specified is characterized by predominant dissociativesymptoms, but does not meet the criteria for one of the other dissociative disorders.4. What are the associated features and disorders of each dissociative disorder?Dissociative Disorder Associated Features Associated Dis0rder.s

Dissociative amnesia Depressive symptoms, depersonali- Conversion disorders, moodzation, trance states, analgesia,and spontaneous age regression disordersguilt, psychological stress, conflict,and suicidal and aggressive impulses

disorders, and/or personalityDissociative fugue Depression, dysphoria, grief, shame, Mood disorders, posttraumatic

stress disorder (PTSD), sub-stance-related disorder

Table continued o following p a g e

25. dual diagnosis - substance abuse and psychiatric illness

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