Dual Diagnosis: Diagnosis and Treatment

In this context dual diagnosis refers to those who have nonnicotine substance abuse or dependence in addition to another axis I or axis II disorder. While statistics vary widely, dual diagnosis occurs commonly in the severe mentally ill, occurring with a prevalence of about one-third in psychiatric inpatients. In the outpatient population, the prevalence of substance abuse is also much higher than in the general population.

Etiology:

In simple terms, people abuse substances in order to either feel good e.g. “get high”, or to feel better, e.g. to self medicate. While most people enjoy feeling good, dual diagnosis patients are generally self medicating as well.

Self medication may be for emotional pain e.g. anxiety, agitation, low self-esteem, depression, and negative symptoms, or physical pain.

When self-medication becomes more harmful than beneficial, the person probably has a problem with substance abuse or chemical dependency.

Diagnosis:

Because of the high prevalence of substance abuse and chemical dependency, and because active substance abusers are at much higher risk of committing suicide and homicide or being refractory to treatment, the diagnosis of these disorders is very important. The incidence of completed suicide in substance abusers is 3-4 times higher than in the general population, and even higher in depressed patients. In severe mental illness, such as is seen schizophrenia and bipolar disorder, the prevalence of dual diagnosis may be greater than 50%. Even if you do not believe these statistics, given the potentially severe consequences if not fatal consequence of not making the diagnosis, it is probably safer to assume that dual diagnosis is the rule rather than the exception.

Transference and countertransference in diagnosis:

While many psychiatrist recognize the importance of taking a good substance abuse history for the psychiatry boards, in practice, many psychiatrists leave taking a good substance abuse history out of their routine practice. Like the rectal exam done by some physicians who ask “you don’t want me to stick my finger up your rear do you? And then record the rectal exam as being refused, serious inquiry about substance abuse is often neglected by psychiatrist for reasons of counter-transference and transference.

The psychiatrist wants to avoid conflict and be liked by the patient and the patient wants to avoid pain and be liked by the psychiatrist. Thus it is essential that the psychiatrist inquire about the substance abuse history in a non-judgmental and non-threatening manner. If the patient understands that your major concern is to help, not punish them, they may open up, if not on the first interview, when you might inquire again later if substance abuse is suspected.

History:

In getting a history, it is important to realize that substance abuse and chemical dependency alone, can mimic almost any other psychiatric disorder. This can occur for several weeks, even once there is total abstinence from the drugs or alcohol.

Substance abuse can affect anyone, and can be active in persons you might never suspect, including high functioning and successful professionals. It is especially prevalent among anesthesiologists, surgeons, and yes-psychiatrists.

If your patient does give a history of substance abuse, it is then helpful to determine if the substance abuse preceded the onset of the symptoms at hand. If so, then the patient may more likely have a substance induced disorder. It is a very serious mistake however, to assume that this is always true.

The contrary is also true. Many chemically dependent patients minimize their early use. They may want you to focus on their symptoms and treatment, rather than the etiology, and thus minimize their early substance abuse history. In many patients the dual diagnosis may have progressed simultaneously, and drug-seeking patients who have been through this line of inquiry before can be especially keen to the fact that they are more likely to be prescribed addictive substances and get disability if they manipulate you by telling you that their problems started before their substance abuse.

Collateral history from family and old records is very useful. Given what we now know about genetics, family history of substance abuse is also very important. Also keep open to the idea that family members who have chemical dependency may have also been medicating another disorder.

Legal history including DUIs, Intoxicated in Public, or Possession are also good clues about substance abuse.

Be careful about “cross-addiction”. Your pt may insist that alcohol or marijuana was their only problem. Alcohol, benzos, and barbiturates affect the same receptors. All substances of abuse affect the pleasure-reward system in the brain. When someone becomes addicted to one substance, they might be at risk with others-no matter what they may tell you.

History obtained during the course of treatment:

Finally, diagnosis may stem from the course of treatment.

Get to know your pt. What do they do all day. If they are on disability, stay home, watch TV, eat the xanax you prescribe with beer chasers all day, reconsider your diagnosis and treatment plan. If their life is improving, they are staying clean and sober, you are probably on the right track.

If serious symptoms persist despite several weeks of treatment with the patient being abstinent from substances of abuse or alcohol, you can be sure they have a dual diagnosis, but only if you are sure they have really been abstinent. This may require hospitalization and or drug screens. Again, collateral history can be very helpful.

Patients who constantly “loose” their addictive medications, and tell you nothing works for them except the addictive medications, may also be suspect. It can sometimes help to get drug levels of all medications in addition to drug screens to insure proper compliance. If it seems that only the addictive substances are being taken, the pt may have only a substance abuse disorder, however, dual diagnosis pts may be noncompliant for the same reasons as single diagnosis pts. They may not understand why you want them to take meds that have a lot of side effects, take a long time to work, and are expensive, over the ones they know from experience work right away, and even make them feel good or even “high” if taken in larger quantities.

Also be aware of addiction versus “pseudoaddiction”. Your pt may appear drug seeking because you have not prescribed enough of what is really helping. Ruling out pseudoaddiction can be a slippery slope, however. You may prescribe liberally and find your pt does great, or you may make your pt much more dependent than ever, and face the difficult task of reducing their meds or detoxing them. Many of these latter pts then go on to seek treatment from other psychiatrists who may then perpetuate the pattern.

Post-Acute Withdrawal:

Be aware of post-acute withdrawal. Even after several weeks, substance abuse pt’s may have severe mood swings, insomnia, and anxiety. Be careful to distinguish between a patient who has an axis I disorder, and one who is axis II or at least has the traits, possibly as the result of long term dependence on substances to deal with problems of mood and anxiety rather than developing the ability to self soothe using several coping mechanisms. These patients, even if they want off of the addictive substances, might want to think of themselves, and you to think of them as persons primarily with a “chemical imbalance” rather than one with characterological problems.

Labs:

Labs can be very helpful. A single drug screen, positive or negative doesn’t tell you much. A mentally ill person may still be using recreationally like many others, or may be trying to self medicate just prior to seeking treatment. Conversely, drug screens, with the exception of those for cannabis, are only sensitive at best to the past few days of use. Furthermore, many pts come seeking treatment when their supply has run out and they are in withdrawal. You may even be ware of the sweet little old lady whose drug screen is negative, despite your prescriptions for various anxielytic-hypnotics, stimulants, and painkillers. ( Be careful though- the sensitivities of the tests may not pick up the medications that you are prescribing). Again, it can help to also check levels of other medications to help determine compliance.

Also be aware that alcohol is most commonly abused substance causing mental illness by far, and routine screening labs such as GGT, AST/ALT, MCV etc. may only pick up on the most severe cases.

Detox and Initial treatment:

Initial treatment often starts with detox. While benzos or barbiturates may be used for sedative hypnotic detox and methadone, LAAM, or eventually buprenorphine may be used for opiate detox, be careful not to enable another addiction. E.G. when detoxing an opiate addict avoid throwing barbiturates at headaches and benzos at anxiety, you may be teaching your pt a bad lesson. Unconventional detox for alcohol may use depakote, tegretol, or neurontin. While the safety of these agents for detox is unknown, they do have the advantage of allowing one to continue a detox on an outpatient basis without having to prescribe controlled substances. Similarly, clonidine can be used for opiate withdrawal. Other agents like phenergan, motrin, and immodium can be used symptomatically for withdrawal symptoms.

For diagnostic purposes, it may also be prudent to hold off on meds in general, so long as the pt is not too sick, e.g. psychotic or in a suicidal depression, and you are not causing undue suffering or putting the pt at risk of complications such as seizures. Again, be aware of post-acute withdrawal. Some pts who you think are dual diagnosis, may clear up entirely on no meds at all. Don’t forget that psychotherapy can also be just as effective as medications in many cases.

Treatment:

In principle, the treatment of dual diagnosis patients is fairly simple. The goal is to basically treat both disorders simultaneously. In general addictive medications should be avoided. While this is true in the general population to some degree, rational decision making can be especially challenged with the dual diagnosis pt. It is generally agreed upon that total abstinence from alcohol and street drugs is the safest policy, but many dual diagnosis patients will not comply, at least initially to this plan, and harm reduction becomes the goal. If controlled substances are prescribed, it is advisable to follow up with the patient on a frequent basis, and one may also consider writing prescriptions that must be refilled weekly in order to discourage abuse.

Countertransference during Treatment:

One must look at their own attitudes towards addiction. Many psychiatrist go into psychiatry to treat mental disorders and are not interested in helping drug addicts and alcoholics. They themselves may have been abused by an alcoholic parent, or have had a loved one killed by a drunken driver. They may not have fit in well with the party crowd in college when studying diligently to get into medical school. While accepting that disorders like depression and anxiety may be inflicted on pts, they may believe that addiction is something people inflict on themselves, that it is a moral disease. The psychiatrist may have a problem with substances in their own life, and thus deny that they or their pt really has a problem. They may feel that drug addicts are trying to use and take advantage of them. They may resent having to admit another one of these pts in the middle of the night who they think should just be able to quit on their own. They should be treating real patients who will love and appreciate them for the treatments they offer.

In response to these issues of countertransference, one should remember that chemical dependency is an axis I disorder. It has a genetic basis. And perhaps, most importantly, becoming addicted to drugs or alcohol and incurring all the related problems is usually not something people have done to themselves intentionally.

By being in touch with your own issues, you can avoid under treating (this guy is just a rotten drug addict, I’m not going to give him any treatment or medications, he is just trying to use me and I’m going to make him pay for it), or over treating (this poor soul has come to ME for help, I’M going to rescue him, his real problem is that no one has prescribed him enough xanax, Ritalin, and oxycontin in the past, those lousy doctors, they have driven my pt to drinking and using illicit substances. I don’t know why they had such a bad relationship with the pt, the pt comes to me all the time, and really shows ME appreciation when I write him the prescriptions. He always tells me that I am really helping him. I’m not too sure how much I will have to keep raising the doses to help him get off of disability though.

Do no harm:

Remember, when your pt comes for help, it is about them, and not you. You are the expert, however. Don’t undertreat out of spite, and don’t let the pt dictate their own treatment so they will love you and not leave you. Help the pt to understand that you are on their side, and you will help them by following appropriate guidelines. To form this theraputic alliance can be most challenging with the dual diagnosis pt. To some degree, this may require some flexibility with following guidelines, just as it does for all pts. For example, you inherit a pt who is on multiple controlled substances, who you are sure is overmedicated big time. You may have to continue these medications for a while until the alliance is strongly established. A good time for making changes in these meds might not be until the pt goes on their next big drinking binge, hits bottom, and comes to recognize for himself, that you may have been right all along, that those prescriptions have really been making things worse. If you find out that your pt has been receiving multiple prescriptions from multiple doctors, I recommend that you talk to your pt about this. Get consent to communicate with the other doctors if this had not already been done earlier in treatment. Use this as an opportunity to adjust the medications. Don’t just drop them from treatment out of spite. Try to help.

Treatment Contract:

Consider making a treatment contract. It is generally good practice to have the pt agree not to get controlled substances from other doctors unless you are made aware of it. Regular drug screening and medication levels can be important. Required attendance in therapy and or 12 step groups is often useful. Have a specific policy for “lost” controlled substances from the beginning, e.g. one lost prescription might be replaced, after that, a lost prescription equals an automatic taper off of the medication. Have a policy for missed appointments, e.g. refills on controlled substances only up to the next available appointment. If pts abuse the policies, you might agree to follow the pt for a month until they can find someone new to treat them. Point out that you are unable to successfully treat someone who cannot follow your guidelines. Professionals like medical personal, and pilots often require special contracts. In Virginia, Virginia Monitoring, Inc., often helps medical professionals in their recoveries.

Anxiety, Insomnia, and Panic:

Many dual diagnosis pts complain about anxiety, insomnia, and panic. As in all patients standard treatments like psychotherapy and SSRIs are useful. Tricyclics are also often useful for pts who have failed on the newer antidepressants and have only been adequately treated for panic and general anxiety with the benzos. While Buspar often does not seem to work, according to good studies, it actually does in many cases. Results with buspar seem especially dismal when your pt has been recently taking benzos. Also non-benzos usually wont start working until the pt has been sober for a while.

While treatment guidelines suggest that benzos should be avoided in dual diagnosis patients, and usually be used only short term in the general population, often dual diagnosis patients insist on being treated with benzos, and want to be treated with them long term. If these patients didn’t have an irrational believe that only benzos can help them, they probably wouldn’t be dual diagnosis patients. Be in touch with your own anxiety. If your pts make you feel anxious that you are not treating them with benzos, you give in to this anxiety, and treat them inappropriately with benzos, you are reinforcing their addiction by behaving in the same manner that they do. Remember that part of what we do, is to teach our patients how to tolerate anxiety to some degree. While benzos often do treat anxiety fairly well, they can also cause depression in long term treatment. They can trigger alcohol relapses. They make the high from alcohol more intense (especially some benzos like xanax), and they are a great self treatment for withdrawal. Thus be careful that you don’t make your patients alcohol dependence far more severe by reinforcing it with benzos.

If you use benzos, the long acting ones like Klonopin are the less likely to be abused. An exception is Valium. It works fairly fast, and is reinforcing in this manner. It has a long half life because of its metabolites. It is often better to prescribe benzos on a standing basis. Addicts and alcoholics often have big problems controlling their intake, one of the things that got them hooked in the first place. It is often easier for them to regulate their meds on a standing basis therefore. Remember that benzos disrupt sleep architecture, dependence to their sedative effects develops rapidly, and are commonly mixed with alcohol. Most alcohol dependent pts and others with CD have insomnia for several weeks into their recovery. Many prolonged their addiction because they felt they needed to in order to sleep. Benzos can continue this pattern.

Most pts with insomnia need to be instructed in sleep hygiene, especially dual diagnosis pts. Ambien or Sonota might be a good choice to help regulate sleep early on, and can be easily discontinued in most cases. Ambien and Sonata have some addictive potential, but do not seem to be so widely abused as are the benzos.

Trazadone was never put through the trials for FDA approval as a hypnotic probably because of financial considerations. Trazadone is actually very effective however. It will work for most people at doses between 50 and 200 HS, and it is not habit forming. Neurontin and other mood stabilizer are also often helpful for anxiety and insomnia. Atypicals such as zyprexa and seroquel can also be helpful. Inderal can work well for panic and social anxiety. Be sure to treat with informed consent, especially as you are using these meds off label. Remember that alcohol and drug withdrawal, especially benzo withdrawal causes panic attacks. Marijuana can also induce panic attacks. Dual diagnosis pts may run out of benzos early, present with panic attacks, and not tell you that they ran out of the xanax 3 days after you prescribed it to them.

Pain:

Pain is very subjective. If practical, have your pts pain meds prescribed through a specialist. Sometimes methadone has the advantage of treating both pain and an addiction to opiates. Treatment of addiction with methadone or LAAM requires a special license. They are proven treatments and can be very useful in motivated pts who have done poorly with abstinance based treatments. While it is essential to take pain seriously, don’t forget that it can also be exaggerated in psychiatric patients and may have a psychosomatic component. Some patients who do not drink or accept that they have anxiety or depressive disorders may end up addicted to prescribed opiates as they focus on their physical, rather than their emotional pain. Be careful about cross addictions. The pts PCP may have hooked them on opiates, you might similarly hook them on benzos or stimulants by conspiring with your pt to ignore the underlying problems which might be more amenable to psychotherapy. Tricyclics and anticonvulsants might also help in selective cases where they treat both the psychiatric and physical disorders.

If pain needs to be treated with opiates chronically, consider methadone preferably prescribed through a pain clinic with other treatments. On a short term basis, e.g. after a surgery, the addict should be assured that they will get adequate pain relief, they often need more opiates than non addicts, possibly due to long term tolerance, should be treated with standing dosing, and tapered off quickly once the acute pain issue has resolved.

Depression and Bipolar disorder:

SSRIs may help your pt cut down on their drinking. A couple of studies have shown desipramine to be effective. If a stimulant must be used, provigil is probably safest.

In bipolar disorder, depakote may have some advantages.

Psychosis:

The atypicals produce less dysphoria, and are probably helpful in that way. Clozaril seems most promising.

Personality disorders:

Treat symptomatically with agents like SSRIs, depakote, and atypicals following general treatment principles.

ADHD:

Wellbutrin, SSRIs, Effexor, imipramine. Avoid amphetamines and Ritalin. Provigil may have some benefit, but probably won’t help hyperactivity. If nothing else works but Ritalin and amphetamines, carefully weigh the risks and benefits.

Pharmacological treatments for addiction:

Antabuse can be a useful adjuctive treatment for alcohol dependence. It is generally useless unless other adjunctive treatments are being used like aa or therapy. This is because pts simply stop taking it, often related to their denial. Antabuse can also be dangerous in the medically sick, impulsive, psychotic, or suicidal pt, and can also have psychiatric side effects. Currently there is research being conducted on the use of antabuse in cocaine dependent patients who use cocaine as a result of disinhibition by alcohol, or as a way of calming their withdrawal.

While there has not been financial incentive for major studies on naltrexone, it doe seem to be helpful in cutting down alcohol cravings and consumption. Type II alcoholics (the ones with strong genetic predisposition, and early onset) may actually feel better while taking naltrexone according to one study. The general population has more risk of dysphoria as naltrexone also blocks the endorphins to some degree. Naltrexone is also a mainstay treatment in encouraging abstinance from opiates. Remember to wait 7-10 days and consider a trial of naloxone, or you might induce severe withdrawal symptoms however. Methadone also has its place as previously discussed. Like antabuse, naltrexone and methadone are seldom helpful alone.

Acamprosate, not approved for use in the United States has a similar structure to GABA and might be of use in treating alcohol dependence.

Conclusions:

While treatment of dual diagnosis is easy in principle-treat both disorders, in practice there are many difficulties. These include getting an adequate history and making the proper diagnosis. It sometimes helps to assume that dual diagnosis is the rule rather than the exception given the serious risk of misdiagnosis. One should be aware of transference and countertransference, and even once a pt is engaged in treatment it may be difficult to maintain compliance with treatment.