by Joseph Browne, Ph.D.,
Center for Addictive Diseases

Although “Dual Diagnosis” may still be occasionally used for people with co-occurring mental illnesses, the designation is now used almost exclusively for people with psychiatric disorders and co-occurring substance abuse or dependence.  When correctly identified, these combined illnesses require highly specialized diagnostic and treatment constructs.  Encouragingly, research on and treatment of dually diagnosed individuals has grown exponentially over the past fourteen years.  Equally encouraging is the decline of such demeaning labels as “double trouble” and such simplistic and reductive responses to addictions as “just say no”—responses which manifest frightening ignorance of the complex psychological, biological, and social etiologies of these multifaceted disorders and their interactions.

Fortunately, as our knowledge of the dually diagnosed increases, so too does our understanding of such multifactorial elements as their genetics, environment, age, and gender as well as our sensitivity to the uniqueness of each person’s mental illness(es) and addictions and how they can severely exacerbate one another. Current advances in neuroscience indicate that molecular and cellular changes take place in the brain as a result of drug and alcohol abuse/dependence. This helps to account for the high rate of relapse among alcoholics and addicts even years after their last use, further complicating sustained and successful treatment of the dual disorders.

The National Comorbidity Survey (1991) states that approximately 10 million people in the United States had dual diagnoses. Because of improved and more comprehensive diagnoses, that number has grown significantly since then.  Other studies reveal that certain mental illnesses, especially schizophrenia, Bipolar Disorder, Anti-social Personality Disorder, Borderline Personality Disorder, panic disorder, and major depression are particularly susceptible to alcohol and drug abuse and dependence.  These illnesses often lead to addiction because of impaired judgment, poor impulse control, and self-medication with drugs and alcohol.  Another major problem is the reluctance of the dually diagnosed to adhere to their medication programs for a variety of reasons, but especially the medications’ side effects which, ironically, may lead back to drugs and alcohol.

Whether or not the mental illness is substance induced must also be determined to facilitate the treatment process.  Quite often, however, it is difficult to determine which disorder came first, although the National Household Survey on Drug Abuse determined that psychiatric disorders generally precede substance abuse and dependence.  Alcoholism probably does precede depression in approximately 70% of dually diagnosed people, but often the dual diagnoses are so intertwined that it becomes relatively impossible to determine cause and effect.

Family involvement in treatment programs for the dually diagnosed can be beneficial, but is often problematic because family members have become so alienated by such addictive behaviors as hostility, theft, lies, and chronic relapse.  Nevertheless, when properly educated about dual diagnosis, family participation can lead to more productive treatments and prolonged improvement of both disorders.  Family and professional involvement is particularly crucial for the growing population of dually diagnosed children and adolescents.  It is not unusual to hear from the adult dually diagnosed that they began using drugs and alcohol as early as nine and ten years of age to cope with various problems and painful feelings or to numb themselves to these problems and feelings which went undetected by parents, teachers, or caregivers.  Parents must become aware of the availability of drugs and alcohol in middle and high schools and attentive to their children’s symptomatic behavior to avoid what could become tragic consequences.

Specialized self-help groups such as Dual Diagnosis Anonymous may be more appropriate for the dually diagnosed than traditional AA or NA groups because most psychiatric disorders can be more effectively accommodated within these special groups. Some psychiatric disorders such as Anti-Social Personality Disorder may do better in individual psychotherapy than in groups.

As psychologists, psychiatrists, therapists, and drug and alcohol counselors become more educated about dual diagnosis and better acquainted with dually diagnosed individuals, our comprehensive diagnoses, treatment modalities, and psychopharmacological interventions will become more specifically relevant, effective, and individualized to create healthier, more productive lives for these human beings who no longer need to suffer the devastating consequences of their illnesses.

###