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Dual Diagnosis

Dual Diagnosis is a term generally used in the field of addiction treatment and, more particularly in the treatment of substance use disorder. It is important to remember that both addiction and mental illness are both highly stigmatised and treatment must take this into account with empathy and sensitivity.

Mental illness may co-exist with addiction
About thirty years ago it became apparent to health professionals treating people suffering from addiction that addiction was not necessarily always the sole or a discrete problem. The understanding grew that other serious mental illnesses and disorders often existed alongside an addiction and interacted with it. Terms were duly coined, such as ‘co-existing’, ‘co-occurring’ and ‘co-morbid’ in reference to such a dual diagnosis. So, someone presenting with an alcohol use disorder, for instance, might also be diagnosed with a clinical depression, or a person admitted for treatment for their benzodiazepine addiction might also show signs of an anxiety disorder, while an individual dependent on heroin might also be found to be suffering from a bi-polar or obsessive-compulsive disorder. A dual diagnosis may also apply in cases of behavioural addictions such as those to gambling, pornography or shopping.

Personality disorder
It is also not uncommon for personality disorders of one kind or another (there are some ten categories) to be identified in people suffering from addictions, with borderline personality disorder perhaps being the most common. The symptoms of this disorder tend to include: emotional volatility, distorted patterns of thinking, impulsive behaviour and intense, unstable relationships with other people. Because it is essentially a disorder of mood and interpersonal relationship, it has similarities with how addicted individuals often present. Self-harm, including suicide attempts may feature in the person’s history, as may eating disorders.

Which came first – the addiction or the mental illness?
The question inevitably arises as to whether the mental illness or personality disorder preceded and perhaps played a part in the onset of the addiction or whether the addiction led to the development of the mental condition or personality disorder. Both scenarios are of course possible and almost certainly an addiction, while sometimes masking a mental disorder, invariably exacerbates it. Due to its wide-ranging impact on all aspects of health, addiction also increases the risk of developing a new disorder, including in some cases, psychosis. Drug-induced psychosis is most likely to feature in addiction to hallucinogens and cannabis, as well as stimulants like methamphetamine and ‘club drugs’ like ecstasy.

It has become increasingly clear that many people develop addictions as a result of their efforts to cope with diagnosed or undiagnosed mental health problems. Consequently this has been termed ‘self-medicating.’ The easy availability and generally fast acting nature of addictive substances hold an attraction for a person struggling to deal with the symptoms of depression, anxiety, with the mood swings of a bi-polar disorder or the disturbing experience of schizophrenia. It may well be that the person is not aware that this is what they are doing. They are just aware of struggling with the emotional and relational aspects of life in some way and needing something to alleviate the stress and distress they experience in the process.

Integration of treatment – closing the gap between specialists
In the past, people with a co-existing mental illness and a substance addiction often found it next to impossible to access treatment for their addiction from addiction specialists. Mental health specialists were similarly often reluctant to treat someone until their addiction had clearly remitted. Thus there was a gap, into which fell many people who were desperately in need of help. Both sets of professionals felt less than fully equipped to treat conditions with which they were both unfamiliar and for which they lacked adequate training and therefore competence. There was also the simple fear of the unknown. As a consequence, many people received ill-informed and inadequate treatment.

Happily it is now generally accepted that a significant proportion of people presenting for treatment for addiction will also be found to be suffering from some other form of mental ill health, whether previously diagnosed as such, or not. This is an important perspective when it comes to seeing the person as a whole, something which treatment programmes are now much more likely to do. Providers are now routinely open to and prepared for, the possibility that a dual diagnosis will apply. It is much better understood how these co-existing conditions also interact.

Changes in practice
The realisation and acceptance of the reality that people suffering from an addiction might also be coping with a mental illness led to changes in practice and also improvements in treatment skills. Rather than treating conditions separately, a far more integrated approach developed. As is the case at our luxury addiction treatment centre, this comes under the clinical management of a multidisciplinary team comprising psychiatrists, psychologists, psychotherapists, counsellors and a variety of complementary therapists.

Detoxification leads to diagnostic clarification
Because addictive substances tend to muddy the physical and psychological waters when it comes to fully understanding the sometimes complex suffering of patients, it makes sense to deal first with any current or recent intoxication. Apart from anything else, safety and stabilisation of health must be the immediate priority. Detoxification, or medically managed withdrawal is also the best route to being able to clarify, as soon as possible, received or provisional diagnoses; sometimes confirming these, sometimes contradicting them. Throughout its course, treatment always involves a process of re-evaluation, with the treatment plan being adjusted as necessary. The diagnostic profile, especially where there is a dual diagnosis, may in time look quite different once the drugs of addiction are out of the system.

Although many people presenting for treatment will have become addicted through self-medicating some version of an undiagnosed mental illness, others will have received a formal diagnosis and perhaps be taking prescribed medication as a result. The effectiveness of such medication is likely to be affected by the consumption of addictive drugs. It will therefore be a vital part of the treatment team’s care to determine what medication should continue and what should no longer be taken. Expert clinical judgement and close monitoring is called for in these circumstances.

… and the alternatives
The team at this private in-patient addiction treatment centre will aim to introduce the person to other ways of managing emotional and mental states that do not rely on the use of chemicals. They are able to draw on conventional therapies such as Cognitive Behavioural Therapy (CBT), as well as a range of complementary options, such as Mindfulness and various forms of exercise – including in uplifting natural surroundings – guided relaxation, massage, equine-assisted therapy and other physical activities that help to improve states of mind and overall wellbeing. The wider the offering the more likely it is that someone will light upon a therapy that works for them as an adjunct to core psychological interventions, such as one-to-one counselling and individual or group psychotherapy.

An environment that communicates care
Addiction and mental ill health are stressful conditions. They are often accompanied by agitated confusion and met with reactions, attitudes and interventions that are at best unhelpful and possibly demeaning, which may even make matters worse. It is essential therefore for treatment to provide an environment that, in every way, signals safety, dignity, care and respect to people whose self-esteem, however well masked, is likely to be at a low ebb. The quality of care is a vital ingredient, encompassing comfortable, well-maintained, clean accommodation, nutritious food and attentive, empathic and well-qualified staff. The support of the community of peers makes an important contribution, lessening the sense of isolation. The quality of the external environment also plays an important role in improving the spirits of psychologically hard-pressed residents.

The treatment team helps families to understand the condition from which a family member is suffering. It may seem confusing and even threatening. The team will guide families in discovering the best way to support the person during treatment. Families individually and collectively experience considerable degrees of anxiety-based distress as they struggle to cope with and make sense of their family member’s illness. That struggle can become as all-consuming as the patient’s addiction and result in less-than-helpful interventions. This is why families both individually and collectively will be offered support in their own right, not just in relation to the person undergoing treatment. Conferences with close family during the patient’s treatment are essential to restoring healthy communication. Plans for support that are likely to prove most helpful beyond treatment can be devised collaboratively.

Reasons for optimism
It is entirely understandable that people and their families approach treatment with an array of conflicting emotions, including hope and fear. Where the complexity of a dual diagnosis applies, pessimism about outcome is not uncommon. However, despite the challenges, there is an excellent chance that with effective help and personal commitment, the path to a sustainable recovery can be laid.