Discussion Notes

Dual Diagnosis
Dr. Kenneth Minkoff

Individuals with Co-occurring Disorders

Principles of Successful Treatment.

• Comorbidity is an expectation, NOT an exception.
  
  
• Treatment success derives from the implementation of an empathic, hopeful, continuous treatment relationship, which provides integrated treatment and coordination of care through the course of multiple treatment episodes.
  
  
• Within the context of the empathic, hopeful, continuous, integrated relationship, case management/care and empathic detachment/ confrontation are appropriately balanced at each point in time.
  
  
• When substance disorder and psychiatric disorder co-exist, each disorder should be considered primary, and integrated dual primary treatment is recommended, where each disorder receives appropriately intensive diagnosis-specific treatment.
  
  
• There is no one type of dual diagnosis program or intervention. For each person, the correct treatment intervention must be individualized according to diagnosis, phase of recovery/treatment, level of functioning and/or disability associated with each disorder, and level of acuity, dangerousness, motivation, capacity for treatment adherence, and availability of continuing empathic treatment relationships and other recovery supports.

Sub-Groups of People With Coexisting Disorders

Patients with “Dual Diagnosis” - combined psychiatric and substance abuse problems - who are eligible for services fall into four major categories.

PSYCH HIGH / SUBSTANCE HIGH
SERIOUS & PERSISTENT MENTAL ILLNESS
WITH SUBSTANCE DEPENDENCE

• Patients with serious and persistent mental illness, who also have alcoholism and.or drug addiction, and who need treatment for addiction, for mental illness, or for both. This may include sober individuals who may benefit from psychiatric treatment in a setting which also provides sobriety support and Twelve-step Programs.

PSYCH LOW / SUBSTANCE HIGH
PSYCHIATRICALLY COMPLICATED
SUBSTANCE DEPENDENCE

• Patients with alcoholism and/or drug addiction who have significant psychiatric symptomatology and /or disability but who do NOT have serious and persistent mental illness.
  
  
• Includes both substance-induced psychiatric disorders and substance-exacerbated psychiatric disorders.
  
  
• Includes the following psychiatric syndromes:
  • Anxiety/Panic Disorder - Suicidality
  • Depression/Hypomania - Violence
  • Psychosis/Confusion - PTSD Symptoms
  • Symptoms Secondary to Misuse/Abuse
    of Psychotropic Medication
  • Personality Traits/Disorder

PSYCH HIGH / SUBSTANCE LOW
SERIOUS & PERSISTENT MENTAL ILLNESS
WITH SUBSTANCE ABUSE

• Patients with serious and persistent mental illness (e.g. Schizophrenia, Major Affective Disorders with Psychosis, Serious PTSD) which is complicated by substance abuse, whether or not the patient sees substances as a problem.

PSYCH LOW / SUBSTANCE LOW
MILD PSYCHOPATHOLOGY WITH SUBSTANCE ABUSE

• Patients who usually present in outpatient setting with various combinations of psychiatric symptoms (e.g. anxiety, depression, family conflict) and patterns of substance misuse and abuse, but not clear cut substance dependence.

DSM III-R Diagnostic Criteria

PSYCHOACTIVE SUBSTANCE ABUSE

• A maladaptive pattern of psychoactive substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
  • Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home
  • Recurrent substance use in situations in which it is physically hazardous
  • Recurrent substance-related legal problems
  • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance use
    
    
• The symptoms have never met the criteria for Substance Dependence for this class of substance.

DSM IV Diagnostic Criteria

PSYCHOACTIVE SUBSTANCE DEPENDENCE

• A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period:
  • Tolerance, as defined by either of the following:
    • A need for markedly increased amounts of substance to achieve intoxication or desired effect
    • Markedly diminished effect with continued use of the same amount of the substance
  • Withdrawal, as manifested by either of the following:
    • The characteristic withdrawal syndrome for the substance
    • The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
      
      
• The substance is often taken in larger amounts or over a longer period than was intended
  
  
• There is a persistent desire or unsuccessful efforts to cut down or control substance use
  
  
• A great deal of time spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  
  
• Important social, occupation, or recreational activities are given up or reduced because of substance use
  
  
• Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  
  NOTE: The following items may not apply to cannabis, hallucinogens, or phencyclidine (PCP)
• Characteristic withdrawal symptoms
• Substance often taken to relieve or avoid withdrawal symptoms

Philosophical & Clinical
BARRIERS TO INTEGRATED TREATMENT

PARALLELS

PARALLELS
PROCESS OF RECOVERY

• PHASE 1: Stabilization
  • Stabilization of active substance use or acute psychiatric symptoms
    
    
• PHASE 2: Engagement/ Motivational Enhancement
  • Engagement in treatment
  • Contemplation, Preparation, Persuasion
    
    
• PHASE 3: Prolonged Stabilization
  • Active treatment, Maintenance, Relapse Prevention
    
    
• PHASE 4: Recovery & Rehabilitation
  • Continued sobriety and stability
  • One year - ongoing

PHASE 1: Stabilization

PHASE 2: Engagement/Motivational Enhancement

• All good treatment proceeds from empathic, hopeful, clinical relationship.
• Consequently, promote opportunities to initiate and maintain continuing empathic, hopeful relationships whenever possible.
• Specifically, remove arbitrary barriers to initial assessment and evaluation, including initial psychopharmacology evaluation (e.g., length of sobriety, alcohol level, etc.)
• Moreover, never discontinue medication for a known serious mental illness because a patient is using substances.
• Never deny access to substance disorder evaluation and/or treatment because a patient is on a prescribed non-addictive psychotropic medication.
• In fact, when mental illness and substance disorder co-exist, both disorders require specific and appropriately intensive primary treatment.
• There are no rules! The specific content of dual primary treatment for each person must be individualized according to diagnosis, phase of treatment, level of functioning and/or disability, and assessment of level of care based on acuity, severity, medical safety, motivation, and availability of recovery support.

For more information about Dr. Kenneth Minkoff, please visit his website at: www.kenminkoff.com

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