Telias, D. (2001) Dual Diagnosis. International Journal of Psychosocial Rehabilitation. 5, 101-110
Definition of Dual Diagnosis
The whole issue of "Dual Diagnosis" is rather conflictive, and it has been addressed from different points of view in literature.
The definition causing some problem is "Dual diagnosis" itself. The term refers of course to the situation in which the same person suffers from more than one condition. But we could say that somebody who has the flu and at the same time suffers from gastroenteritis has "Dual diagnosis".
In more common use, Dual Diagnosis refers to the situation in which somebody suffers from a mental disorder and is also dependent or addicted to some substance.
When the term "Dual Diagnosis" is used in the USA, it often refers to any mental disorder plus some substance abuse.
In Israel, we prefer to use the term "Dual Diagnosis" to refer to a person who suffers from a condition determined under Axis I of the DSM IV classification (1), which refers to Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention. The diagnosis specifically omits Personality Disorders and Mental Retardation.
The difference of conception between the USA and Israel is based mostly on economic reasons. Insurance companies pay for the treatments in the USA, and they have decided that the treatment for Substance Abuse or Dependence should be one week, which is obviously only enough for, in the best of cases, completing the physical withdrawal period, but not for the rest of the treatment. As a result, therapeutic sources have decided to treat the (usually) accompanying Personality Disorder as an entity separated from the addictive disorder, in order to justify the extension of time used for the treatment, and the use of the term "Dual Diagnosis" has become much more common.
In Israel, the treatment of addictions is paid by the State, and it is substantially more comprehensive than the current approach accepted in the USA, and consequently, we can spare the term Dual Diagnosis for cases in which an Axis I diagnosis other than the addictive disorder is found. These patients are treated separately from either psychiatric or addictive patients, as will be described further on.
We have been using the term "Addiction" in the old sense, we should mark that a distinction is now made between two terms which were used rather indistinctly until a few years ago: Addiction and Dependence. The difference, as seen now, consists of the following:1. Addiction (Drug addiction)The term means that the person continues using the substance because he/she fears the consequences of the abstinence syndrome produced by the sudden cessation of the use. The anatomical location is in the Hypocampus.
The term is often used indistinctly with "Dependence", but the meanings, and even the anatomical location of the two conditions, are different. Addiction means that the person continues using the substance because he/she likes the effect produced by the substance. The anatomical location is in the Ventral Tegmental Area.
2. Dependence (Substance Dependence)
It is useful to remember that the distinction between Addiction and Dependence, recently elucidated, may help explain the controversies respect to some substances like THC (cannabinoids), which were considered by some as "Addictive" and by others as "Non (or Almost Non) Addictive", before the distinction was noted.
The incidence of Dual Diagnosis is very difficult to determine, specially if we take into consideration that nobody can really tell what is the incidence of Addiction or Dependence in the population.
-1) - About 20% of the adult population of the USA suffer from some form of addictive disorder throughout their lives;
-2) - Approximately 25% of the adult population in the ECA study had some form of Axis I diagnosis besides the addictive problem;
-3) - Of this 25%, about half (12.6%) suffered from major depression and about 5% could be diagnosed with psychotic, bipolar and other disorders;
-4) - Women substance abusers show a high incidence of PTSD as comorbidity (3).
-5) – About 30% to 50% of schizophrenic patients may meet the diagnostic criteria for alcohol abuse or alcohol dependence; the two most commonly used other substances are: cannabis (15 to 25%) and cocaine (5 to 10%) (4).
-5) – Every fifth psychiatric inpatient abuses opiates or cocaine; every fourth one abuses some illegal substance; every third one abuses alcohol (5).
-6) – About 60% of patients with schizophrenia, and about 58% of all psychiatric inpatients abuse or are dependent of at least one substance (6,7).
American statistics do not match well with Israeli population, but we can assume that a high proportion of substance abusers in Israel have another form of Axis I diagnosis as comorbidity.
We should note here that Heroin abuse is, at least by the time being, more common in Israel than Cocaine abuse, consequently, some of the references found in American literature should be adapted when referred to Israel. Alcohol abuse, which receives in Israel much less attention than Heroin abuse, is increasing, and some statistics place the number of people dependent from alcohol at about 60.000. (8)
Order of appearance
The question of what disorder appears first is often raised. The answer is not simple. Alcohol abuse was found to be prior to first admission in 24% of cases (9, 10), and other substance abuse in 14%, which is double the rates in the general population.
The same source states that there is some evidence that alcohol abuse precedes schizophrenia, while it is possible that the first hospitalization due to schizophrenia is more or less coincident with the beginning of opiate abuse.
Practical problems in the management of dually-diagnosed
Although it is generally accepted that addictions are part of the Psychiatric field, in practical terms psychiatrists do not like addicts, and addiction treatment centers do not like mental patients.
As a result, patients presenting the comorbidity of addictive disorders and mental disorders are underdiagnosed and receive very little treatment.
Most psychiatric hospitals will admit addicts for very short periods when there is a significant psychotic decompensation, but will discharge them as soon as the acute phase of the disease is over, or, sometimes, as soon as the dual diagnosis is discovered.
Addiction treatment centers usually do not admit patients who are overtly disarrayed from the psychiatric point of view. Those patients are referred to psychiatric facilities, and the procedure starts all over again. Some attempts are being made to improve the situation (11, 12).
The situation in Israel
Until 1993 there were no services specialized in the treatment of dual diagnosis in Israel. At the beginning of 1994 the first beds for these patients were open at the Mental Health Center Beer-Sheva’s Rehabilitation Department.
In that opportunity the patients were chosen from the Negev area, in cooperation with the addiction-treatment facilities existing in Beer-Sheva. The degree of cooperation between the teams in the two areas made it possible to start a program specifically aimed at patients who suffered from dual diagnosis with the characteristics mentioned above: An Axis I diagnosis besides the addictive problem. Inter-team cooperation was assured by inserting some members of the Mental Health Center staff into the addiction-treatment facilities.
It soon became evident that, although the teams were cooperating and trying to provide the best possible set of treatments under the circumstances, patients and their families were not so cooperative.
The Israeli society is quite different from the American, and family ties in Israel are much stronger than in the USA.
The majority of addicts in Israel still is from North African origin, and they consider as "family" the extensive family. It is customary to visit relatives, who are unwell, especially if they are admitted in hospitals.
Since the rehabilitation department is an open ward, where patients can enter and leave at will, it was very difficult to control the visits of families and friends of the patients. The families and friends often felt obliged to bring those addicted patients something with what to feel better, including of course their favorite substances of abuse.
At the same time, it soon became evident that visitors were profiting from their visits to sell drugs to other patients, and sometimes even to abuse male and female psychiatric patients.
The management of the Mental Health Center then decided that, although it was very meritorious to treat dually diagnosed patients, and although the management was much interested in continuing the treatment, a drastic change in procedures had to be implemented in order to permit the adequate functioning of the institution and at the same time treat the dual diagnosis patients.
It was decided that a new kind of unit, of the closed type, had to be created.
The search for the means with which to build the facility started. At the same time, when the word spread in Israel that there was an interest to open a dual-diagnosis unit, some other psychiatric facilities started to study the possibility to open that kind of unit.
Administrative and logistic problems of many kinds started to appear.
One of the psychiatric facilities, located in a general hospital in the North of Israel decided to use a few empty rooms they had to start a dual diagnosis unit. The project had to be abandoned when the nursing staff of the hospital menaced to collectively abandon their jobs if addicts were admitted in the facility.
A psychiatric hospital succeeded in opening a detoxification unit for dually diagnosed patients, but with very limited objectives: a very short admission period, only for male adult patients, very few beds, no after-care.
The funding for our facility was difficult to find, and it was made available mostly due to a specific interest in the subject that could be elicited at the Anti Drug Authority. The Authority finally came up with a substantial part of the building cost, and the Ministry of Health made the rest available.
Finding the personnel to staff the unit was not simple. Most nursing staff refused to work in a unit where addicts would be admitted, because they feared the violence usually accompanying the admission of addicts. It took several months of training the staff to lower the degree of anxiety that the presence of addicts produced. Finally, when the facility started functioning, and the patients showed absolutely no degree of violence, the personnel started to relax and cooperated fully with the treatment.
After solving some other minor administrative problems, the new unit
was finally open in June 1999.
The unit has capacity for 15 inpatients, and it also comprises facilities for occupational therapy and sport, as well as the usual dinning-room and nursing facilities.
The unit is of the one-way closed type, that meaning that visitors are not allowed, and patients cannot leave on vacations. On the other hand, every patient may ask for discharge at any time, but once he/she leaves the facility, he/she cannot return until after five years.
The selection program established requires that patients, who are referred from all over Israel, sign an agreement to cooperate with their treatment.
Referrals are accepted only from institutions and not from patients themselves or their families. The reason for this is that institutions which refer patients to the unit have to sign an agreement to receive the patients back and continue treatment in their own facilities, or in other facilities which they have to look for, after the patients are discharged from the dual diagnosis unit.
This agreement serves two purposes: On one side, nobody wants Beer-Sheva to become the national concentration point of every dual-diagnosis patient in Israel, so they have to return to their place of origin. On the other side, and most important, those patients who are re-placed in other institutions, are usually receiving antipsychotic medication. When they are re-placed in other institutions, they have to continue taking their medication, which forces the institutions which previously refused to accept patients taking medication to accept them.
In this way, it is hoped that, in a few years, a great part of the present rejection of patients taking medication will disappear, and those patients will be more easily received in the different treatment centers.
No referrals are accepted from the judiciary, and the unit does not serve instead of prison.
The first step in the process is an adequate diagnosis. Most patients were never correctly diagnosed before their admission in the unit, due to the rejection of the psychiatric personnel to treat addicts.
After the diagnostic procedure, which is performed ambulatorily, patients are admitted in the unit, preferably while they are under influence. This is because most patients are dependent on opiates or alcohol. The withdrawal syndrome from opiates or alcohol begins some 8 to 12 hours after the last use. Since the patients have to come from different parts of Israel, and admission hours are in the morning, if the patients were not under influence when they arrive, they would start developing the withdrawal syndrome upon arrival, and management should be much more difficult.
It is our clinical observation that many schizophrenic patients who abuse drugs do not present symptoms of schizophrenia while they are under influence or at least the symptoms are much less pronounced. But the symptoms reappear when they stop using substances, especially when they stop using opiates. This is another reason to prefer that patients arrive in the unit while under influence.
A period of not more than 8 hours must be profited since the moment the patient is admitted until we start the treatment for the withdrawal syndrome and for the psychotic situation.
Withdrawal is assisted with Clonidine unless otherwise indicated, and antipsychotic medication is used according to the needs of the case. The great majority of patients require antidepressant medication.
After medication has stabilized them, and since the first day in the unit, patients are required to participate in the chores of the unit: cleaning and making order not only in their rooms but also in the public areas of the unit. Cleaning personnel is only used to take care of the offices of the staff.
Activities are planned to start at 7.30 in the morning and continue until 10.00 p.m., with lunch and dinner breaks, and a 2-hour rest period after lunch.
Besides medication, patients receive group therapy and counseling, and
participate in educational and rehabilitational groups. Elements of rehabilitation
school have been incorporated into the program (13). Sport activities are
carried out within the premises.
A case description
In order to give a better idea of the kind of patients being treated in the facility, we will see a case history: The history of K"
K' was a strange character when he arrived. He was an addict of course, but there was something else.
K' was born into an apparently "normal" family, was the third of four brothers, had a normal infancy and started school at the normal age. A doctor, a nurse and a psychologist checked him, and they did not find anything wrong.
Because the family's economic situation was poor, they lived in a problematic neighborhood and there never was too much food at home, although they never went hungry.
When K' reached puberty his behavior changed. He began to run away from school and wander around, generally alone. He would sometimes go to a nearby farm in which he could find horses, and he would spend hours on end with them. He did not ride them, he only wanted to feel them near him.
Some time later he started hearing voices, or maybe it was at the same time, he was not sure. The voices were pleasant. They told him that he was not stupid, and that he could do great things in life. He rather liked his voices, and he would listen to them rather than to real people.
Sometimes he thought that it was the horses that were speaking to him, but he could not be sure.
His family was worried about his vagrancy, and they took him to a doctor, but K' did not tell the doctor about his voices. Somehow he felt that the voices were "his", and that telling about them would in some mysterious way harm him. He was also afraid that if he told about them, the voices would go away, and then he would feel lonely.
Since the doctor did not find anything wrong, he prescribed some vitamins, and attributed his behavior to a reaction to adolescence, frequently found in children of his age and background.
But K' refused to go back to school, and the parents decided to leave him alone. The doctor had said that the reaction would eventually pass and he would return to himself.
For the next two years K' was left alone by his family. He would go home to eat and sometimes also to sleep, but would keep his family at a distance, without more verbal contact than the utterance of some words from time to time.
He did not have friends either. He had never been very sociable, and the few friends he had lost interest in him when he left the school. K' was happy with his voices and the company of the horses.
But one day things started changing. Suddenly the voices stopped being nice to him. Sometimes they would curse him; sometimes they would threaten him. One day the voices ordered him to burn the field where the horses were, and he did. No great harm came of this, but the owners of the farm were very upset. They had become used to seeing him play around with the horses, and had never interfered, but the burning of the field was something else.
They had seen him in the field a short while before the fire, and they naturally questioned him. They were under the impression that he had dropped a cigarette, and that the cigarette had caused the fire, but K' told them that he had done it because the voices had ordered him. He found it natural to obey them.
The farmers contacted his parents, and K' was taken to a psychiatric hospital for assessment.
The doctors had no doubt about his condition: Paranoid Schizophrenia. K' was admitted to a closed ward, because he was dangerous to himself and to others. Under the influence of his voices he had burnt the field, but he could as well have killed somebody.
K' was very unhappy at the hospital. Some people were very aggressive in the ward, and beat him. The nurses injected medicines. There were no horses. A patient tried to rape him. He decided to leave, and he escaped from hospital.
He was afraid of returning home, because he thought his family would send him back to the hospital, so he simply wandered around. He ate what he found, and a couple of times he stole some fruit or a roll, nothing serious, only sufficient to calm his hunger. He was 17 at the time.
One day he was walking and feeling very hungry, when he saw a group of people at the side of the road. He approached them and asked for food, and was received very well. They gave him food and beer, and after some hours he felt "at home" with them.
Suddenly one of the men produced some H', and everybody smoked. He was also invited to smoke it. K' was not sure what it was, but the people had been nice and friendly to him, so he tried.
This first experience with H' opened up a new world for him. Suddenly, there were no voices, and he felt calm and relaxed. The sensation of relief also produced an unbelievable well being and exhilaration. K' felt at ease with himself and with the world, for the first time in many years. He asked for more, but was told that the material was very expensive, and that if he wanted more, he should produce some money for it.
K' had never worried about money, and did not have a clear idea of how to make money, so he asked, and was told that rich people usually have a lot of money, and that he could steal it from them.
Very soon K' was very busy with his new "profession". He was not stupid, and despite his schizophrenia, could break into apartments at night and get money with which to buy H'.
The police arrested him for the first time when he was19. He was not so naive now. His friends had also told him that if he spoke with the judge about his voices, he would probably be sent to a psychiatric hospital, and not to jail. He tried, and the judge did send him to a hospital for evaluation.
The hospital confirmed the diagnosis of schizophrenia and drug addiction, and the judge decreed that he should be hospitalized for treatment.
There followed a whole series of hospitalizations for short periods, discharges from the hospital as soon as the acute phase of his schizophrenia remitted, and new arrests and admissions.
All told, he had been in 5 hospitals when he got to me, and was not any better.
K' was in very bad shape when first examined. He looked pale and emaciated, with a frightened look in his eyes. He was unshaven, not very clean, his clothes in disorder.
He had been referred to the dual diagnosis facility because the psychiatrists who examined him first had considered that, though schizophrenic, his drug problem was first priority, and should be treated first.
When asked what his problem was, he said: "The voices don't let me rest. I haven't slept for at least two weeks. I don't want to eat, I want help". His expression was very pathetic, he really looked as though he needed help.
Very careful questioning disclosed that Heroine was what he most appreciated, because when he was intoxicated his voices would give him respite. But he needed very high doses to calm the voices down. When asked about the effect of antipsychotic medication on him, he said that he did not like antipsychotics, because when he had had enough of them to silence the voices he also felt very heavy, drowsy, and could not think clearly. He had received very high doses of antipsychotic medication in the past, as could be seen from his medical record.
There was some reluctance to give him the high doses of Methadone he requested, so he was admitted and started on different combinations of medication. It took almost a month to find the adequate combination.
K' started feeling better, his voices were not bothering him, he was not feeling heavy, and he could think and work. He started putting on some weight.
After one month with the new medication, K' was working everyday, looked happy, was helpful in many ways in the ward, but was shy and made few friends. We started working on that. His therapist had read a lot about psychotherapy with psychotic patients, and he knew that it is generally a very long and complicated process, not always fruitful. It was agreed that we were not looking for a psychotherapeutic cure for his schizophrenia, we only wanted to make him a little more sociable.
With that goal in mind, they set to work. K' was very cooperative, he was really anxious to make friends, but was afraid, since he did not know how.
K' never became one of the leaders of the ward, or one of the most prominent figures, but he did his part, was active, and worked. He did not get involved in problems, never used illicit drugs, at least as far as his urinalysis showed, and was not generally different from the rest of the population of the unit.
He was transferred from the dual diagnosis unit to the rehabilitation department, where he continued his treatment.
The rest of the story shows the importance of opiates for schizophrenic patients.
When he had been some months in the rehabilitation department, he asked to have his medication reduced. He was advised not to do it, but he was very insistent.
At a determinate point, he left the ward without coordinating his departure with the medical personnel. He simply got up one day and left.
A few days later he was readmitted in the short-term unit, showing signs and symptoms of an acute psychotic state.
The staff at the short-term unit called us in, to consider readmission in the rehabilitation unit, so there was a chance to check him. When asked for the reasons of his sudden decision to leave the hospital, he confessed that reducing the medication had been a mistake. Voices started bothering him again, but he was ashamed of asking to raise his medication, after he had been so adamant in requiring it to be reduced. So, the only way out he found was to star using opiates again. Opiates immediately calmed his voices down, by the did not want to stay in the rehabilitation department while using opiates, he thought it was unfair with the staff, who had treated him decently, so he decided to leave.
On readmission, he quit opiates at once, and continued doing well with adequate doses of antipsychotic medication.
2. Regier, DA; Farmer, ME; Rae, DS; et al: Comorbidity of mental disorders with alcohol and other drug abuse-results from the Epidemiologic Catchment Area (ECA) study. JAMA 264: 2511-2518, 1990.
3. Najavits LM; Weiss RD; Shaw SR:The link between substance abuse and posttraumatic stress disorder in women. A research review. Am J Addict 1997 Fal; 6(4):273-83.
4. Kaplan, H.I.; Sadock, B. J. – Synopsis of Psychiatry, 8th edition. Baltimore, Williams and Wilkins, 1998.
5. Modestin, J.; Nussbaumer, C.; Angst, K. et al: Use of potentially abusive psychotropic substances in psychiatric inpatients. Eur Arch Psychiatry Clin Neurosci; 247(3): 146-53, 1997.
6. Addington, J.; Duchak, V.: Reasons for substance use in schizophrenia. Acta Psychiatr. Scand. Nov; 96(5): 329-33, 1997.
7. Lambert, M.T.; Griffith, J.M.; Hendrickse, W.: Characteristics of patients with substance abuse diagnosis on a general psychiatry unit in a VA Medical Center. Psychiatr. Serv. Oct; 47(10): 1104-07, 1996.
8. Hambrecht, M.; Hafner, H.: Substance abuse and the onset of schizophrenia. Biol. Psychiatry Dec 1; 40(11): 1155-63, 1996.
9. Dixon L - Dual diagnosis of substance abuse in schizophrenia:
and impact on outcomes. - Schizophr Res 1999 Mar; 35 Suppl():S93-100.
10. Minkoff K, Regner J.- Innovations in integrated dual diagnosis treatment in public managed care: the Choate dual diagnosis case rate program. J Psychoactive Drugs 1999 Jan; 31(1):3-12
11. Ahrens MP.- A model for dual disorder treatment in acute psychiatry in a VA population. J Subst Abuse Treat 1998 Mar; 15(2):107-12
12. Umansky, R.; Telias, D.; Tzidon, E.; Kotler, M. – A school for mental health inpatient preparation for reinsertion in the community. Int. J. Psychosocial Rehab. (online edition), August, 1999.
(Return to Cover Page)