Dual Diagnosis and Facilitating Change Flashcards
What is dual diagnosis?
AKA: Co-morbidity/Co-occurrence
More than one diagnosis
2 or more health problems
Medical, Mental health, Alcohol and Drug, Intellectual Impairment, etc…
Distinctions:
Heterotypic / Homotypic
E.g. mental health and physical disorder vs 2 mental health disorders
Concurrent / Successive
E.g. alcohol dependence and depression at same time vs panic disorder in teenage years and cannabis abuse in twenties
Incidence of dual diagnosis
“The statistics on sanity are that one out of every four Americans is suffering from some form of mental illness. Think of your three best friends. If they’re okay, then it’s you.”
Incidence of dual diagnosis (DD)
20-30% of population will experience MH disorder in lifetime
Over 12 months, 18% experience MH disorder in Australia
10% anxiety, 8% substance use, 6% affective (NSMHW, 1997)
If have MH disorder
likely to have substance use issues and vice versa
How likely? – considerable variation in the answer
DD Prevalence estimates range from 30-90%
Why does it vary?
Depends on diagnostic criteria (Severe, Axis I/II, PD, Sub-clinical)
Setting (e.g. A&D vs MH, treatment vs community)
Specific groups (e.g. Indigenous, homeless)
Gender also a factor
Incidence of Dual Diagnosis
In alcohol and drug settings Mostly anxiety, depression, and personality disorders Some psychosis/schizophrenia In mental health settings Mostly alcohol and tobacco 67% nicotine use in those with Psychosis Some cannabis/speed/heroin
Causal hypothesesDepression
Depressants – general depressant effect
Alcohol
Interferes with medications
Long term effect on relationships, employment, health, etc…
Cannabis
Long-term use may cause ‘depression-like’ symptoms
Hypothesised ‘Amotivational syndrome’
Opiates
Lifestyle related factors associated with opiate dependence
Stimulants
Existing depression may get worse when coming down
Common in the months following cessation
Use/abuse may worsen the sleep / wake cycle
Causal hypotheses Anxiety
Depressants - Agitation, anxiety, and irritability common features of withdrawal
Alcohol
Alcohol related problems can create new worries
Cannabis
Paranoia a common symptom of intoxication
Stimulants
chronic use - anxiety states and panic
high doses - obsessive cognitions and compulsive behaviours
Causal hypotheses Psychosis
Reinforcing effect of drugs related to dopamine
Dopamine hypothesis - Psychosis
Cannabis
Hypothesised to precipitate psychotic episodes
Some evidence suggests a causal link, but still debated in literature
Pharmacology and potency (THC vs CBD; Dose-response)
Cannabis use known to increase rates of hospitalisation, psychotic relapse and psychotic symptoms
Synthetic Cannabis a largely unknown area, but anecdotal reports are concerning
Stimulants
May directly cause psychotic episodes
Amphetamine psychosis: brief psychotic reaction that may last for several weeks
Can this trigger a more chronic psychosis?
Alcohol
Negative symptoms worse and affects treatment
Non-compliance with medication and higher relapse rates
Now think about poly-drug use…
What happens to the mental state when a cocktail of drugs are used?
Uppers and downers cycle
Simulates Bipolar Affective Disorder?
Causal hypothesesMH leading to A&D disorders
Depressant drugs used as a form of “self-medication” of anxiety symptoms
‘Social lubricant’
Stimulant drugs used as self-medication of depression
‘Pick me up’
Pain relieving drugs to manage chronic emotional pain/trauma
Opiates and sedatives commonly linked to a Hx of trauma (up to 90%)
‘Drowning your sorrows’
Cannabis to manage issues with low appetite
Stimulants used to supress appetite
Discussion Question
Steph is 22 years old and had used speed on and off for the last five years
After a particularly heavy use period over four days she starts to get very paranoid and after attacking her parents, she is taken to hospital by police
When she is assessed, she is diagnosed with a drug induced psychosis and after spending a week in hospital appears to have completely recovered
Consider:
What might happen when she tries to return home to her parent’s house?
What are some of the other challenges Steph may face now that this event is in her history?
What if it happens again?
Why is dual diagnosis of concern? Issues for the client
Greater severity of Disorders:
More hallucinations, depressive symptoms and suicidal ideation
Relapse risk increased
Rehospitalisation
Effects on medications
Loss of support networks/extra challenges:
Unstable accommodation, criminal justice system
Family / relationship issues / stress
Double stigmatisation
Harder to receive/access service
Lack of education
Forensic mental health/legal issues
Poorer self care:
Increased risk taking behaviour (esp. HIV)
Issues for treatment services
-Complex presentations
More than one drug use/mental health issue
Psycho-social issues
-Diagnoses are often unclear
Lack of screening
Misdiagnosis
-Lack of dual expertise or awareness of issues
Lack of confidence in DD
-Added work vs more effective work perceptions
-Lack of flexibility in service provision
Appointment based models
-Confronts clinicians own issues?
Diagnostic issues: Schizophrenia
Positive symptoms Hallucinations Delusional thinking Disorganised speech Negative symptoms Flattened affect Lack of motivation Poverty of speech
Diagnostic issues: Depression
Depression Low mood or irritable Loss of interest in things Appetite issues/weight variations Sleep problems Reduced activity Lack of energy Guilt/worthlessness Poor concentration Suicidal ideation
Relationships b/w MH & SUD
Use of substances causes or exacerbates an underlying mental health problem (Primarily Substance Abuse)
Mental Health disorders lead to substance use and abuse (Primarily Mental Health, e.g. Self-medication)
Mental health disorders and substance abuse disorders develop together and reinforce each other (Bi-directional Model, e.g. Benzodiazepines and Depression)
Both MH and SUD disorders develop somewhat independently of each other due to common causes or risk factors (Common Factors, e.g. Trauma/Adversity/etc…)
Regardless of relationship, usually become inter-connected over time and result in a worsening clinical picture
Case Example:
Bill attends a counselling service and was assessed and diagnosed with alcohol dependence, anxiety disorder and being highly stressed. He reported his father was a violent alcoholic and during the past 12 months Bill had a relationship breakdown and lost his job.
Research perspectives
Research provides no clear answer on causal relationships
Causal link has been demonstrated in both directions
Regardless, neither will assist in the recovery from, treatment of, or relapse prevention of the other
Best way to manage is not dependant on cause
concurrent treatment and management
Treatment Models: Sequential
Sequential - One disorder is treated before the other
Best suited to situations where it is thought one disorder is secondary to the other, where the symptoms that look like a second disorder are really related to the first and there is no real comorbidity at all
Difficulty in determining if the disorders are separate
Conflicts within and between services about who will treat the person eg. A&D say its MH; MH say its A&D
Very difficult to say a relationship doesn’t exist between the symptoms
Approach restricted to situations where the evidence shows that a particular procedure can’t be effectively delivered until a specific symptom is addressed.
Treatment Models: Parallel
Parallel - two different practitioners/treatment teams deal with the two separate problems
Current common model
Advantage that both disorders are getting simultaneous treatment
Disadvantages: treatments mistimed or act in conflict different services goals little info sharing no co-ordinated response - Who is taking prime responsibility for case management? Black hole
Treatment models
Specialised dual diagnosis service
Development of expertise
Duplicated infrastructure Resource intensive Communication??? Who is suitable Very high prevalence of dual diagnosis clients in all services
