Dual Diagnosis: Substance Use and Co-Occurring Mental Disorders

Introduction

The abuse of substances and dependence on them are considered to be two separate types of disorders, according to the DSM-V. The DSM-V is a manual used by professionals in the fields of medicine and mental health, specifically for diagnosing disorders related to a patient's mental health and substance use. Through this manual, there is a standardized way of diagnosing such disorders (Rockville, 2005). Substance use disorders are often found to co-exist with other disorders. This paper highlights the assessment and treatment of substance-related disorders and their co-morbid conditions.

Co-Occurring Mental Disorders and Substance Use

The DSM-V progresses from the DSM-IV in that it places disorders on a spectrum, replacing the separate diagnostic categories that were previously used. This spectrum moves from mild to acute presentations. The DSM-V further classifies the use of specific substances into distinct disorders, with the exclusion of caffeine. Other changes include the requirement that at least two symptoms be identified for a disorder to be diagnosed as mild — drawn from a list of 11 symptoms provided by the DSM-V. This differs from the DSM-IV, which required just one symptom for a mild disorder diagnosis. The DSM-V has also added drug craving as a symptom while removing criteria that do not apply globally, such as negative encounters with law enforcement (American Psychiatric Association, 2013).

Professionals working with substance abuse patients must be aware of the co-occurrence of mental disorders and substance use disorders, as well as conditions that present similar symptoms — such as withdrawal or intoxication. This awareness is intended to help counselors become more familiar with the terminology surrounding mental disorders and to better assist patients who exhibit these symptoms (Rockville, 2015).

Counselors who deal with addiction are most likely to encounter personality disorders, as is typical in quadrant III substance abuse treatment settings. People with personality disorders exhibit traits that persist long-term, leading to social and occupational dysfunction. Symptoms manifest through their thoughts, emotions, interpersonal interactions, and impulse control. Counselors can observe these symptoms by noting the patient's perception of the world, how they think about themselves and others, the intensity of their emotions, how they respond to specific situations, and the nature of their relationships (Rockville, 2005). Flynn et al. (1997) note a high co-occurrence of substance abuse and antisocial personality disorder, and treatment for substance abuse has been more frequently directed toward those suffering from this disorder.

Psychotic disorders are characterized primarily by problems with cognition. These include hallucinations and delusions. Delusions affect a person's thoughts based on false premises and can hinder their functionality — for example, a person may believe they are in danger from others or mistake their own identity. In hallucinations, a person may perceive things that do not exist: seeing, hearing, smelling, or feeling stimuli that are not present. Psychotic disorders are more prevalent in mental health settings, and when combined with substance abuse, the abuse tends to reach severe levels. This population represents the most severely and persistently mentally ill. Gustafson (1999) notes that this population has increasingly been seen in substance abuse treatment programs. Substances such as cocaine can induce delusions and hallucinations beyond simple drug toxicity, and a psychotic person may exhibit these symptoms following intoxication (Rockville, 2005).

Some symptoms of mood disorder include an inability to properly express emotions, or the expression of emotions that are inappropriate or excessive. While it is normal for individuals to experience emotional highs and lows, a person with a mood disorder experiences these states at levels well beyond the norm. Mood disorder may co-occur with a substance abuse disorder and may even influence the type of substance used. Depression, mania, and bipolar disorder are among the common presentations of mood disorder (Rockville, 2005).

Risk Factors for Substance Abuse

Substance abuse has been observed across all age groups except early childhood. There are particular developmental periods when the risk is elevated. Adolescence is one such period, characterized by peer pressure, self-discovery, and a heightened sense of invincibility. The psychopathology of a child is greatly affected by having parents who abuse substances and by having deviant peers (Moss et al., 2002). Where a parent has a substance abuse problem, children raised in that environment are more likely to begin abusing substances themselves — particularly when peer pressure is also present.

Hansell and Demour (2005) note that men are more likely than women to abuse substances. Research in this area has examined the genetic contribution to this problem. One finding is that alcoholism tends to recur across generations of the same family, with 25% of male children of alcoholic parents becoming alcoholics themselves. In a study by Bierut et al. (1998), researchers examined how dependence on substances such as cocaine and marijuana is distributed within families. They found that dependence on these substances, as well as on alcohol, was elevated among siblings of those who were alcohol-dependent. These siblings were more likely to develop dependence on cocaine, marijuana, and alcohol. This suggests that dependence on these substances is habitual, and that both common and substance-specific factors are transmitted within families. A client whose father was a drug addict may be genetically predisposed to developing the same addiction.

Repeated exposure to stressful circumstances also increases the likelihood of developing substance abuse. Stress can have a significant impact on substance use — it has been found to initiate alcohol use, sustain it, and contribute to relapse following a period of abstinence.

There is also a relationship between substance abuse and specific social factors. For example, rates of abuse are higher among young, unemployed males than in the general population, and elevated rates are also found in high-stress occupations. The field of medicine, for instance, has higher rates of drug abuse than most other professions. Thus, sociocultural factors play a role in substance abuse. As proponents of family risk factors have observed, patterns within families — such as codependency or denial of a problem — can contribute to a member's drug addiction (Hansell and Demour, 2005).

The environment and social company a person keeps can also influence substance use (Powell, 1973). In one study of heroin users, respondents reported that their identity was tied to the practices of the group they belonged to. This phenomenon is supported by behavioral theory: positive and negative reinforcement in operant conditioning explains how substance users experience pleasurable feelings when consuming drugs and use substances to avoid unpleasant thoughts. Cravings can develop through classical conditioning, in which drugs become associated with feelings of belonging, friendship, and other rewarding experiences (Collins, Blane & Leonard, 1999; Hansell & Demour, 2005).

Conclusion

For dual diagnosis, a patient's life is fully encompassed, including their lifestyle, preferences, and timing. Effective individualized intervention must include educating the client, targeting recovery across multiple life domains, and involving the client in decision-making. In this way, the client can commit to a treatment path because they participated in its design. Client involvement also ensures that the program remains helpful, as the effects of medications can be monitored and assessed. When supporting clients — particularly with regard to employment — the approach should actively encourage abstinence from substances. Clients can also be trained in social skills that help them form friendships and manage encounters with those who sell or use substances (Mueser, Noordsy & Drake, 2003).

In dual diagnosis treatment, peer groups are among the most significant factors. Groups are highly regarded as an intervention strategy for those with substance abuse disorders. The intensity, organization, and style of the group should match the stage of recovery the clients are in. Long-term group attendance has been shown to be effective; however, no single group format has proven superior to others. The focus should therefore be on matching the client to a group they find appropriate and comfortable (Drake, Mueser & Brunette, 2007).

Where outpatient treatment does not produce improvement, long-term residential treatment is recommended. These programs may vary in structure, but certain elements are essential: a duration of over one year, explicit attention to relapse, integrated treatment for co-occurring disorders, and ease of entry and discharge. Some housing-first programs enable homeless clients to participate and work toward meaningful recovery goals.

There should also be a sustained focus on improving quality of care. This can be achieved through system engineering, electronic record-keeping, the use of electronic decision-support tools, and regular review of clients who are not showing improvement (Hermann, 2005).