Dual Diagnosis: An Overview

Research and study of the brain is beginning to unlock the mystery of dual disorders. For years the psychiatric field has either ignored dual diagnosis (a dual diagnosis was impossible prior to DSM III due to exclusionary criteria and DSM I & II forbidding’ multiple diagnoses), or treated personality as the underlying cause of substance abuse.’ The addiction field believed abstinence from mood altering drugs would cause the psychiatric symptoms to disappear. Research has not found a single underlying personality variable to account for substance abuse disorders, nor has addiction research found the remission of psychiatric disorders with abstinence. Both theories have highlighted the need for research/treatment specifically aimed at the complexities of dual diagnosis. Some research suggests deficits in neurological functioning as a precursor for dual diagnosis in some people ( Chappel etal. 35). Self-medication of’ Axis I disorders, and symptomatic relief of Axis II diagnoses has also been cited as the cause of dual disorders (Kessler et al., 1996; Walker, 1992).’ Others highlight psychosocial factors such as poverty and parental absence (Rahav et al., 1995), physical and sexual abuse and neglect (Henderson et al., 1994; Alexander et al., 1994), and cultural norms of the inner city (Rhav et al., 1995), as playing pivotal roles in the development of dual diagnoses. In fact some (Jones & Katz, 1992), suggest that the lack of concern for issues related to dual diagnosis is directly related to many being poor minorities. While the two diseases do exacerbate each other there are numerous causal interactions that must be addressed to lead to more specific diagnosis and effective treatment strategies.

The term dual diagnosed began to surface in the 1980’s. The development of DSM-III with its multiaxial system and allowing of multiple diagnosis began the identification of dually occurring psychiatric and substance use disorders. The former Commissioner of Mental Health in Tennessee, Evelyn Robertson states, over the past 20 years the deinstitutionalization movement has indirectly created a generation of chronic patients with a high prevalence of alcohol and drug abuse (200). With the development of Jellinek’s “disease model” of alcoholism (Jellinek, 1960), and the founding of Alcoholics Anonymous (a self-help program that assists individuals who seek sobriety through mutual support of other recovering individuals) substance abuse treatment began to flourish. This posed a problem for many physicians, and especially psychiatrists, who viewed alcoholism as the result of an underlying personality disturbance (Ridgely, Goldman, and Willenbring 125), or a disease to be treated by the addiction field. The primary goal of treatment in the recovery model is abstinence from mood altering substances. This conflicts with the psychiatric model that stresses emotional stability and commonly involves the use of medication. The ambiguous concept of the recovery model emphasizing “powerlessness” while the psychiatric model emphasizes “empowerment” is just an example of the philosophical differences (Sheeham 109).’ In the 1993 article Sheehan states,’ “The recovery model stresses addiction as the primary driving force behind the addicts’ problems.’ Simply stated, this model asserts that abstinence resolves the “psychiatric symptoms”.’ In contrast, the psychiatric or psychodynamic model identifies psychiatric symptoms or some deeper psychiatric conflict as the motivating force behind chemical abuse and dependence.”(109)

This population is growing at an alarming rate and the latest epidemiological data (Kessler et al., 1996) suggests a 79% rate of dual diagnosis in those meeting criteria for any single psychiatric disorder. These researchers found that during the year previous to data collection only 1/3 of these people sought treatment. In a 1997 Tennessean article “Double Trouble” Quigly reports 25,000 tennessean’s suffer from dual disorders.’ Dixon and Osher report the staggering number of people with this illness is growing at such a pace it is overloading our public health system (3).’ Treatment for the dual diagnosed may depend on who the treatment professional(s)/provider(s) is/are and their theoretical orientation.’ Howland states, “As a result, conflicts may arise about the responsibility for the direction of treatment, leaving the patient confused or having to chose one over the other” (1135).’ Patients are often left feeling unsure if anyone can help since they often get conflicting stories from treatment providers. In short, the responsibility for integrating treatment falls on the least capable individual, the consumer.

Recommendations for overcoming these problems include unification of these disparate approaches into an integrated system which could promote cross-training for the professionals/providers and the managed care system.’ Howland states, ” Ideally, funding and programming for mental health and substance abuse should be brought together into one system, rather than categorically distributed between separate systems” (1135).’ Providers have historically been unwilling to allow this to happen due to being over protective of their turf and being afraid of further reductions in funding.’ Two united systems could promote education, training and planning in both areas, allowing the providers to gain expertise in both domains.’ Comprehensive psychiatric and substance abuse evaluations should be performed no matter where the patient presents for treatment.’ Preferably, treatment centers would provide specialized services for the dual diagnosed client with both treatment professionals working together simultaneously with both problems, instead of with the predominant issue (Howland 1135).

Foundations Associates is an example of an integrated treatment model for the dual diagnosed.’ Today, Foundations has expanded the scope of services to provide an integrated continuum of care that includes respite care, half way houses for men and women, “step-up” houses for senior residents of the program, and educational workshops for the dual diagnosed.’ The treatment team includes a psychiatrist, psychologist, licensed clinical social worker and addiction counselors.’ For more information on dual diagnosis research, treatment or educational opportunities contact:

Michael CartwrightExecutive Director, Foundations Associates220 Venture Circle.Nashville, TN’ 37228Toll Free (888) 869-9230Local (615) 742-1000

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