Dual Diagnosis: A Clinical Challenge


The literature concerning dual diagnosis has largely identified and defined the mental health “element”of this phenomenon as the presence of a functional psychotic illness(such as schizophrenia, bipolar disorderdelusional disorder, schizo-effective disorder, or depressive illness with psychotic symptoms), but is less specific when identifying the substance use “element” of the dual diagnosis (Phillips, 1998; Phillips & Johnson,2001)

From a clinical perspective it can be argued that this definition is excessively narrow since it excludes those patients with non-psychotic mental health problems(such as personality disorder, depressive illness, anxiety, or phobic or eating disorders) from the potential benefit of any specialist help or evidence based intervention available to those with substance use disorders and functional psychotic illness. This is especially pertinent since the presence of non-psychotic mental health problems is well established among those with substance use disorders (Baker et al.,2004; Farrell et al., 2003)


Dual diagnosis is a term for when someone experiences a mental illness and a substance abuse problem simultaneously. Dual diagnosis is a very broad category. It can range from someone developing mild depression because of binge drinking, to someone’s symptoms of bipolar disorder becoming more severe when that person abuses heroin during periods of mania. Either substance abuse or mental illness can develop first. A person experiencing a mental health condition may turn to drugs and alcohol as a form of self-medication to improve the troubling mental health symptoms they experience. Research shows though that drugs and alcohol only make the symptoms of mental health conditions worse. Abusing substances can also lead to mental health problems because of the effects drugs have on a person’s moods, thoughts, brain chemistry and behavior.


Why Do Some People Develop a Co-occurring Disorder While Others Don’t?

Researchers continue to search for a definitive answer to this question. Currently, the belief is that dual diagnoses come about as a result of a combination of variables. Chief among them are genes, stressful or traumatic events, and early drug exposure, all of which can overlap and interact with each other at various times in someone’s life.1

Which psychiatric illness comes first – substance abuse or the other co-occurring disorder – depends on the person and their circumstances. Sometimes substance abuse can lead to mental illness. For example, the onset of depression is common among those whose relationships, careers and/or health have deteriorated as a result of substance abuse. Conversely, mental illness can bring on drug abuse. Anxiety, for example, can lead people to abuse alcohol and other drugs to find relief from their symptoms.

It can be difficult to determine which illness came first and which is responsible for the other. This is why seeking professional help from trained clinicians and medical experts is a vital component of successful treatment. Determining in what ways one or more psychological disorders are interacting with a drug use disorder can be extremely beneficial to one’s recovery.

While most people with concurrent disorders get better with treatment, there are some factors that can inhibit or slow down their progress.

  • Most important is an undetected co-occurring mental illness. Undetected illnesses pose a risk to treatment dropout and relapse.
  • Those who develop a mental illness before a substance use disorder may be at higher risk of enduring a difficult treatment process.
  • Severe, co-occurring major depression and/or post traumatic stress disorder (PTSD) may also provide additional strain and hinder treatment progress.
  • And, lastly, recent evidence suggests that continued use of tobacco during treatment can be a risk for post-treatment relapse.

There are a number of different talk therapies, but the following have been shown to be especially effective in treating a number of dual diagnoses:

  • Cognitive-behavioral therapy (CBT) involves recognizing and changing thoughts and behaviors that encourage drug use and negative thinking.
  • For people with self-harm and impulsive tendencies, Dialectical Behavioral Therapy (DBT) may be particularly helpful.  
  • Some individuals prefer group therapy, which can also improve social skills and provide a support group.  
  • Exposure therapies are especially helpful for individuals suffering from severe anxiety and panic attacks, as well as post-traumatic stress.  
  • Therapeutic communities are designed to help those suffering from domestic violence or homelessness.
  • Assertive Community Treatment targets those with severe mental illness such as schizophrenia.  
  • There are also separate facilities that treat dual diagnoses in adolescents.  


The following posts have some case studies and their results. Care, read and share to help!






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