Evaluating & Managing
The Dual Diagnosis Patient
Peter A. DeMaria, Jr.., M.D., FASAM
Coordinator of Psychiatric Services
Tuttleman Counseling Services
Clinical Associate Professor of Psychiatry & Behavioral Sciences
Department of Psychiatry & Behavioral Sciences
Temple University School of Medicine
Philadelphia, Pennsylvania
Case Study A
Anne is a 19 year old student who tells you that
she has been diagnosed with ADHD, anorexia
nervosa, depression, borderline personality
disorder and alcoholism. She is prescribed
methylphenidate (Concerta), citalopram
(Celexa), quetiapine (Seroquel) and
alprazolam (Xanax). She recently had a
relationship break-up. She feels her
depression is getting worse and she has
started to drink again. She appears of average
height and weight.
Case Study B
Brian is a 20 year old student who complains of
problems with concentration and focus. He
finds that he forgets to do important things;
this forgetfulness has caused problems with
his schoolwork and in his relationship with his
GF. He has a well documented ADHD history
and would like to restart his stimulant. He
reports that he likes to party with his friends
on the weekends and smokes MJ during the
week to help him relax and sleep.
Case Study C
Bill is a 21 year old student who presents
stating that he has mood swings and
can’t sleep. He has a history of binge
alcohol and cocaine use, but says he
hasn’t had any cocaine in a month.
Presenting Psychiatric Symptoms
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Anxiety
Depression
Insomnia
Psychotic symptoms
Disruptive behavior
Causes of Psychiatric Symptoms
• Drug intoxication or withdrawal states
• Medical illness
• Psychiatric comorbidity
The Challenge
Mental
Illness
Dual
Diagnosis
Substance Use
Disorder
Definition of Addictive Disease
Addiction is a primary, chronic disease with
genetic, psychosocial, and environmental factors
influencing its development and manifestations.
The disease is often progressive and fatal. It is
characterized by continuous or episodic
impaired control over drinking or drug use,
preoccupation with alcohol or drugs, use of
alcohol or drugs despite adverse consequences,
and distortion in thinking, most notably denial.
(Adapted
from the NCADD and ASAM Definition of
Alcoholism.)
Chronic Disease Model
• Prototypes: CAD, HTN, DM
• Development and course reflect an
interplay of genetic vulnerability,
pathophysiology, and personal behaviors
• Treatment focuses on management not
cure
• Goals include highest quality of life
• Patient must take an active role in
treatment
• Compliance is frequently an issue
Substance Use Is a Spectrum
Disorder
Abstinence
Experimentation
Substance abuse
Substance dependence
Lifetime Prevalence of Comorbidity - ECA Date
Mental Disorders, 22.5%
Comorbidity = 29%
•Alcohol = 22%
•Other drug = 15%
Alcohol Disorder, 13.5%
Comorbidity = 45%
•Psychiatric - 37%
•Other drug = 22%
JAMA 264(19):2511-2518,1990
Other Drug Disorder = 6.1%
Comorbidity = 72%
•Psychiatric = 53%
•Alcohol = 47%
Epidemiology of Dual Diagnosis
• ECA Study: Alcoholics have 1.5 - 2 x higher
incidence of depression than general population
• Alcoholics:
– At intake 70% have moderate to severe
depression
– 4 - 6 weeks after detox 10-20% had major
depression
• Psychiatric inpatients at McLean Hospital: 60%
of males and 40% of females met criteria for
alcohol or drug abuse or dependence
Epidemiology of Dual Diagnosis
• Cocaine addicts at McLean Hospital: 27% had
affective illness.
• Opiate addicts: 54% had lifetime incidence and
24% had current episode of major depression.
• 15.2% of respondents in the NCS who had
ADHD met criteria for any substance use
disorder (3 x the rate of respondents without
ADHD).
The Biopsychosocial Spiritual Orientation
Biological
Psychological
Spiritual
Social
The Biopsychosocial Spiritual Orientation
• Biological
– Genetics
– Health issues
– Brain chemistry
• Social
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Living unit
Relationships
Work/school
Cultural factors
• Spiritual
– Organizing principles
– Morals/ethics
– Cultural factors
• Psychological
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Self esteem
Identity
Object relations
Drives/defenses/
conflicts
Developmental history
Trauma/abuse
Personality traits
Relationships
Dual Diagnosis
“Dual diagnosis is an expectation,
not an exception.”
-Dr. Kenneth Minkoff
www.kenminkoff.com
The Four Quadrant Model for
Co-Occurring Disorders
Both High Severity
Mental Illness
High Severity
Substance Use Disorder
Low Severity
Mental Illness
Low Severity
Substance Use Disorder
High Severity
Both Low Severity
A guide to treatment planning.
Disorder Parallels
Addiction
Major Mental Illness
A biological illness
A biological illness
Heredity (in part)
Heredity (in part)
Chronic disease
Chronic disease
Incurable
Incurable
Leads to lack of control of
behavior and emotions
Leads to lack of control of
behavior and emotions
Positive & negative
symptoms
Positive & negative
symptoms
Disorder Parallels
Addiction
Major Mental Illness
Affects the whole family
Affects the whole family
Progression of the disease
without treatment
Symptoms can be
controlled with proper
treatment
Disease of denial
Progression of the disease
without treatment
Symptoms can be
controlled with proper
treatment
Disease of denial
Facing the disease can lead Facing the disease can lead
to depression & despair
to depression & despair
Disorder Parallels
Addiction
Major Mental Illness
Disease is often seen as a
“moral issue” due to
personal weakness rather
than having biological
causes
Feelings of guilt and failure
Disease is often seen as a
“moral issue” due to
personal weakness rather
than having biological
causes
Feelings of guilt and failure
Feelings of shame and
stigma
Physical, mental, &
spiritual disease
Feelings of shame and
stigma
Physical, mental, &
spiritual disease
Screening-Assessment-Treatment
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High index of suspicion
Screen everyone; revisit regularly
Assess which Stage of Change
Engage in treatment
Use Motivational Interviewing techniques
Use behavioral/contingency contacts
Involve others
Consult/Refer
Stages of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Differentiating Substance Related Disorders
from Psychiatric Disorders
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Relationship of symptoms to drug use
Which came first?
Presence of symptoms during periods of sobriety
Past treatment history
Atypical presentation
Poor or unpredictable response to treatment
Family history-psychiatric or addiction
Look for common co-morbidities:
– Bipolar disorder and alcoholism
– ADHD and substance abuse
– Cluster B personality traits/disorder
General Approach to the Dual
Diagnosis Patient
• Comprehensive biopsychosocial spiritual
assessment.
• Engage patient in treatment and develop a
therapeutic relationship.
• Develop a treatment plan
– Addressing both psychiatric & addiction issues
• Assess response
• Adjust treatment plan
Treatment Planning
• Treatment planning must be individualized.
• The treatment plan must follow a careful
assessment.
• The treatment plan is not static, it is dynamic
and changes as the providers learns more and
the patient changes with interventions.
• Develop a treatment team utilizing the
expertise in other clinicians.
• Ensure regular and thorough communication
between all treatment team members.
Possible Treatment Modalities
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Individual counseling/therapy (psychiatric/addiction)
Group counseling/therapy (psychiatric/addiction)
Self-help (12 step) programs
Behavioral/contingency management
Couple’s Therapy
Family therapy
Disability Resources & Services Involvement
IOP/Partial hospitalization
Inpatient psychiatric (dual diagnosis) hospitalization
Psychotropic medication (psychiatric/addiction)
Issues Specific to College MH Practice
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Hospitalization necessary/indicated?
Treat in-house or refer out?
Is drug screening available?
Must the student be clean for everything?
If not, what is acceptable?
What support is available on campus?
Pharmacotherapy of Addictive Disorders
• Detoxification
• Aversive agents
– Disulfiram (Antabuse)
• Anti-craving Agents
– Naltrexone (ReVia, Vivitrol)
– Acamprosate (Campral)
– Bupropion (Wellbutrin, Zyban)
– Varenicline (Chantix)
Pharmacotherapy of Addictive Disorders
• Maintenance pharmacotherapy
– Nicotine replacement therapy (NRT)
• Patch, gum, inhaler, lozenge
– Opioid maintenance pharmacotherapy
• Methadone
• Buprenorphine (Subutex/Suboxone)
General Approach to
Psychopharmacology
• Use biopsychosocial spiritual model
• Avoid addictive substances (e.g. BZ)
• Treat psychiatric condition if it prevents
engagement in addiction treatment.
• Avoid making psychiatric diagnosis and
initiating medication until 2-4 weeks into
abstinence from substances.
• Less is better
Case Study A
Anne is a 19 year old student who tells you that
she has been diagnosed with ADHD, anorexia
nervosa, depression, borderline personality
disorder and alcoholism. She is prescribed
methylphenidate (Concerta), citalopram
(Celexa), quetiapine (Seroquel) and
alprazolam (Xanax). She recently had a
relationship break-up. She feels her
depression is getting worse and she has
started to drink again. She appears of average
height and weight.
Case Study B
Brian is a 20 year old student who complains of
problems with concentration and focus. He
finds that he forgets to do important things;
this forgetfulness has caused problems with
his schoolwork and in his relationship with his
GF. He has a well documented ADHD history
and would like to restart his stimulant. He
reports that he likes to party with his friends
on the weekends and smokes MJ during the
week to help him relax and sleep.
Case Study C
Bill is a 21 year old student who presents
stating that he has mood swings and
can’t sleep. He has a history of binge
alcohol and cocaine use, but says he
hasn’t had any cocaine in a month.