Dual Disorders: Concepts and Definitions
The Relationships Between Alcohol and Other Drug Use and Psychiatric Symptoms and Disorders
Establishing an accurate diagnosis for patients in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric disorders and psychiatric symptoms caused by alcohol and other drugs (AODs). To do so, clinicians must obtain a thorough history of AOD use and psychiatric symptoms and disorders.
There are several possible relationships between AOD use and psychiatric symptoms and disorders. AODs may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process.
The primary relationships between AOD use and psychiatric symptoms or disorders are described in the following classification model (Landry et al., 1991a; Lehman et al., 1989; Meyer, 1986). All of these possible relationships must be considered during the screening and assessment process.
- AOD use can cause psychiatric symptoms and mimic psychiatric disorders. Acute and chronic AOD use can cause symptoms associated with almost any psychiatric disorder. The type, duration, and severity of these symptoms are usually related to the type, dose, and chronicity of the AOD use.
- Acute and chronic AOD use can prompt the development, provoke the reemergence, or worsen the severity of psychiatric disorders.
- AOD use can mask psychiatric symptoms and disorders. Individuals may use AODs to purposely dampen unwanted psychiatric symptoms and to ameliorate the unwanted side effects of medications. AOD use may inadvertently hide or change the character of psychiatric symptoms and disorders.
- AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes. Cessation of AOD use following the development of tolerance and physical dependence causes an abstinence phenomenon with clusters of psychiatric symptoms that can also resemble psychiatric disorders.
- Psychiatric and AOD disorders can coexist. One disorder may prompt the emergence of the other, or the two disorders may exist independently. Determining whether the disorders are related may be difficult, and may not be of great significance, when a patient has long-standing, combined disorders. Consider a 32-year-old patient with bipolar disorder whose first symptoms of alcohol abuse and mania started at age 18, who continues to experience alcoholism in addition to manic and depressive episodes. At this point, the patient has two well-developed independent disorders that both require treatment.
- Psychiatric behaviors can mimic behaviors associated with AOD problems. Dysfunctional and maladaptive behaviors that are consistent with AOD abuse and addiction may have other causes, such as psychiatric, emotional, or social problems. Multidisciplinary assessment tools, drug testing, and information from family members are critical to confirm AOD disorders.
The symptoms of a coexisting psychiatric disorder may be misinterpreted as poor or incomplete “recovery” from AOD addiction. Psychiatric disorders may interfere with patients’ ability and motivation to participate in addiction treatment, as well as their compliance with treatment guidelines.
For example, patients with anxiety and phobias may fear and resist attending Alcoholics Anonymous or group meetings. Depressed people may be too unmotivated and lethargic to participate in treatment. Patients with psychotic or manic symptoms may exhibit bizarre behavior and poor interpersonal relations during treatment, especially during group-oriented activities. Such behaviors may be misinterpreted as signs of treatment resistance or symptoms of addiction relapse.
Alcohol and Other Drug Use and Psychiatric Symptoms
- Alcohol and other drug (AOD) use can cause psychiatric symptoms and mimic psychiatric syndromes.
- AOD use can initiate or exacerbate a psychiatric disorder.
- AOD use can mask psychiatric symptoms and syndromes.
- AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes.
- Psychiatric and AOD use disorders can independently coexist.
- Psychiatric behaviors can mimic AOD use problems.
The Terminology of Dual Disorders
The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders. Recently, within the fields of mental health, psychiatry, and addiction medicine, the term has been popularly used to describe the coexistence of a mental health disorder and AOD problems. The equivalent phrase dual disorders also denotes the coexistence of two independent (but invariably interactive) disorders, and is the preferred term used in this Treatment Improvement Protocol (TIP).
The acronym MICA, which represents the phrase mentally ill chemical abusers, is occasionally used to designate people who have an AOD disorder and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. A preferred definition is mentally ill chemically affected people, since the word affected better describes their condition and is not pejorative. Other acronyms are also used: MISA (mentally ill substance abusers), CAMI (chemical abuse and mental illness), and SAMI (substance abuse and mental illness).