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Complexities of Dual Diagnosis

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Many clients who are diagnosed with substance abuse and addiction disorders also exhibit a psychological disorder. The prevalence and complexity of a dual diagnosis makes it imperative that a clinician knows how to properly diagnose and work with substance abuse clients who also meet the criteria for psychological disorders. The term co-occurring disorders is sometimes used to describe this feature (Stevens & Smith, 2018). In this case, Jerome, a 48-year-old male, has a long history of homelessness, a 20-year old addiction to crack cocaine, a history of arrests, and exhibits key features of a psychotic disorder- hallucinations, delusions, disorganized thinking (speech), and abnormal motor behavior (unpredictable agitation). Jerome may also be experiencing withdrawal symptoms. Stimulant withdrawal symptoms include a dysphoric mood with physiological changes developing within a few hours to several days (APA, 2013).

Psychomotor retardation or agitation, exhibited by Jerome, as he reports of not having used cocaine for three days, is a symptom of stimulant withdrawal. Psychotic, mood, and anxiety disorders are the most common co-occurring mental illnesses with a substance use disorder (Stevens & Smith, 2018). It is important for the clinician to discover whether the presenting symptoms of a psychological disorder either preceded the onset of the problems or persist after the substance use has been treated and a period of abstinence has been maintained for several months. On the other hand, substance use can lead to mental health issues. Functional consequences of abusing stimulants, in Jerome’s case, cocaine, can result in stimulant-related mental disorder symptoms. As stimulant-induced disorders may resemble primary mental disorders, the mental disturbances resulting from the effects of stimulants should be distinguished from the symptoms of a psychotic disorder, such as schizophrenia. Dual diagnosis can be difficult to detect. When SUDs and psychological disorders occur together, potential problems with the diagnostic process increase.

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There are four broad issues that reflect the complexities of dual diagnosis.

Firstly, “combinations of SUDs and psychological disorders may represent two or more independent conditions, each of which is likely to run the clinical course relatively unique to that disorder’s (Schuckit, 2006, p. 76). This would require the clinician to comprehensively treat both conditions. The combinations of these conditions may simply occur through chance, or be a consequence of predisposing factors, such as stress, personality, additional psychiatric disorders, childhood environment, and genetic influences affecting the risk for multiple conditions (Volkow, 2004). Jerome’s long history of homelessness and the resulting stress may be predisposing a factor as well as a possible psychotic disorder before his use of cocaine.

Secondly, the first disorder may influence the development of the second in such a manner that the additional disorder runs an independent course. For example, Jerome’s high dose intake of cocaine could have unmasked a predisposition toward a psychological disorder or cause physiological changes in the brain, resulting in long-term or permanent psychoses. Moreover, a psychological disorder could increase the risk of repetitive and heavy use of substances, and a SUD might continue despite having a pre-existing psychological disorder treated, or itself, remitted (Schuckit, 2006).

Thirdly, if the second disorder/condition developed through an effort of the client in diminishing issues associated with the first disorder, a third relationship could be seen. Jerome may have increased the use of cocaine and developed a SUD in an attempt to alleviate the symptoms of a psychotic disorder as his concern is when I stop, the Devil comes after me. Therefore, if the pre-existing psychological disorder is addressed, the excessive use of drugs may disappear.

The fourth issue focuses on syndromes that may be temporary psychiatric pictures (e.g. psychotic features resembling schizophrenia) as consequences of substance intoxication or withdrawal conditions. This may also pertain to Jerome, given the psychotic features he exhibits may be a consequence of long-term cocaine abuse or current withdrawal symptoms as a result of him ceasing drug use. These comorbidities have important implications in that the etiologies may be different and several categories are likely to have distinct clinical courses and responses to treatment (O’Brien & Charney, 2004).

Symptoms illustrated by Jerome are indicative of schizophrenia and stimulant use disorder. Psychosis, marked by severe dysfunction and dramatic symptoms are very much like medical illnesses. However, bearing in mind, individuals with substance-induced psychotic disorder may present with symptoms characteristic of criterion A for schizophrenia. This should be determined by the relationship of substance use onset and remission of psychosis in the absence of using the substance. Stimulant toxicity can lead to stimulant-induced psychotic disorder, which resembles schizophrenia with hallucinations and delusions. Diagnosis can be difficult as symptoms related to other disorders may be accentuated or modified by clients substance use. For example, an underlying change in brain circuits, an important characteristic of a SUD, may mimic the disturbances of thought and behavior of schizophrenia.

Symptoms of intoxication or withdrawal of substances may also imitate behaviors, negative symptoms, and cognitive deficits seen in psychological disorders. Both the psychological disorder and the substance use disorder need to be treated as separate entities as they both have unique symptoms (Torrens, Gilchrist, & Domingo-Salvany, 2011). It is helpful to question the client’s psychological history before the use of drugs and seek information about a family history of psychological problems, as genetic factors that contribute to schizophrenia might also contribute to addiction. Psychotic spectrum disorders commonly co-occur with SUDs. Substances can cause or exacerbate psychotic symptoms from acute to chronic presentations and half of all individuals who present with psychotic disorders such as schizophrenia, will have a co-occurring SUD (Koola et al., 2012). Active substance use can increase risk of criminal offending, reduces the chance of patients with schizophrenia being helped into the workforce, and is associated with high risk of early death (Schmidt, Hesse, & Lykke, 2011, p. 228).

Although the mechanisms that underlie the comorbidity between SUDs and schizophrenia are poorly understood, the involvement of dopaminergic pathways are a likely shared feature to all drugs of abuse. As the mesolimbic dopamine (DA) pathway has been implicated in the occurrence of positive symptoms in schizophrenia, drug intoxication from cocaine can trigger acute psychotic episodes (Volkow, 2009). The comorbidity of a SUD and schizophrenia may also be due to a direct consequence of schizophrenia neuropathology, contributing to enhanced addiction vulnerability by disrupting the neural substrates that mediate positive reinforcement (Volkow, 2009, p. 469).

Lastly, psychosocial factors such as homelessness/poverty, in Jerome’s case, may also account for a portion of the increased comorbidity due to both disorders being associated with greater exposure to stressors. Schizophrenia spectrum and other psychotic disorders are defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior, and negative symptoms (APA, 2013). In specific, he does not maintain eye contact, constantly moves and shifts in his seat, and switches from one topic to another. This may depict abnormal motor behavior which manifests itself from childlike silliness to unpredictable agitation. He talks of being on top of this whole planet, and it’s hot! I feel like you ever eat yogurt?

Jerome also illustrates the feature of disorganized thinking, in which the individual derails from one topic to another. He also reports hearing voices directing him to deliver the message of the good to people he meets and uses religious references in a number of statements about daily living. This signifies auditory hallucinations; perception-like experiences that occur without an external stimulus. Although he expresses the desire to stop using cocaine, his concern is that when I stop, the Devil comes after me. Here, Jerome illustrates a delusion; a fixed belief that isn’t amenable to change in light of conflicting evidence. In specific, the content of his delusion fits within the persecutory theme (i.e., belief that one is going to be harmed, harassed). On the other hand, Jerome has a 20-year addiction to crack cocaine, a long history of homelessness, and a history of minor arrests. The essential feature of a SUD is a cluster of behavioral, cognitive, and physiological symptoms that indicate the client continues using substances despite significant substance-related problems (APA, 2013).

Overall, the diagnosis of a SUD is based on a pathological pattern of behaviors related to the abuse of substances. Substance-induced mental disorders are “potentially severe, usually temporary, but sometimes persisting central nervous syndromes that develop in the context of the effects of substances of abuse, medications, or several toxins (APA, 2013, p. 487). Individuals exposed to cocaine can develop stimulant use disorder within one week (APA, 2013). Aggressive behavior, paranoid ideation, and psychotic episodes that resemble schizophrenia are seen with high-dose cocaine use. Individuals with acute intoxication may illustrate rambling speech, transient ideas of reference, paranoid ideation, and auditory hallucinations (Caton et al., 2005). These are usually recognized as the effects of the drug by the abuser. Irritability and disturbances in attention and concentration also occur during withdrawal. Therefore, to be considered a substance-induced mental disorder, the disorder being observed is not likely to be better explained by an independent mental condition.

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