Clients With a Dual Diagnosis
According to the National Mental Health Association, 29% of all people diagnosed as mentally ill abuse either alcohol or drugs.
Chemical dependency is a serious public health problem. For people with mental illness, comorbid chemical dependency can be a catastrophic life problem.
Learning objectives
After studying this chapter, you should be able to:
Define the term dual diagnosis.
Explain the acronyms MICAA, MICA, and CAMI.
Differentiate the two main theories related to the development of a dual diagnosis.
Describe the defining characteristics of clients with a dual diagnosis.
Articulate the barriers to effective treatment of a client with a dual diagnosis.
Interpret the four categories that have been developed to describe the dually diagnosed client.
State why it is difficult to assess a client with a dual diagnosis.
Summarize the following phases of treatment for clients with a dual diagnosis: acute stabilization, engagement, prolonged stabilization, rehabilitation and recovery including continuum of care.
Explain why evaluation of a dually diagnosed client’s progress is an ongoing process.
Key Terms
CAMI
Dual diagnosis
MICA
MICAA
Persuasion
Self-medication hypothesis
Vulnerability model
The term dual diagnosis is used to refer to coexisting or comorbid conditions. In the field of psychiatry, dual diagnosis refers to the existence of a serious mental illness and the problematic use of alcohol or other drugs, or both. (Please note that this term has also been used to describe the presence of a psychiatric illness in developmentally disabled clients. These clients are not included in this discussion.) It has been estimated that approximately 50% to 75% of severely mentally ill clients have a dual diagnosis. For example, approximately 1 in 12 clients (7.8%) with a psychiatric diagnosis such as schizophrenia abuses substances and is human immunodeficiency virus (HIV)-positive. Furthermore, approximately 37% of clients who abuse alcohol and 53% of clients who abuse drugs have at least one serious mental illness such as bipolar disorder or an eating disorder. Children with conduct disorder are at risk for abuse of drugs or alcohol, and individuals with depression or anxiety often use alcohol or substances to alleviate symptoms. In addition, approximately 20% of incarcerated substance abusers have a history of mental illness (Baker, 2002; Blinder, Blinder, & Sanathara, 1998; Finkelstein, 1999a, 1999b; Kirn, 1999; National Alliance for the Mentally Ill, 2006; Vaccaro, 1999). Table 32-1 ranks the prevalence of substance-related disorders in clients with a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) diagnosis.
Various acronyms have been used to describe dual diagnosis. The first acronym is MICAA (Mentally Ill, Chemically Abusing, and Addicted), which implies that the primary diagnosis is severe mental illness and the secondary diagnosis is chemical abuse or addiction. The drug most commonly used is alcohol, followed by marijuana and cocaine. Prescription drugs such as tranquilizers and sleeping medicines may also be abused. For example, the term MICAA would be used to refer to a client with schizophrenia who abuses alcohol. This acronym has been shortened to MICA (Mentally Ill, Chemically Abusing) by some professionals. The acronym CAMI (Chemically Abusing, Mentally Ill) implies that the primary diagnosis is chemical abuse and the secondary diagnosis is mental illness. Nearly all the psychiatric disorders, such as delirium, dementia, or depression, can be precipitated by the use of addictive substances. An example of CAMI is the client who abuses alcohol and develops alcohol-related dementia or Korsakoff’s psychosis.
Planning care for clients with a dual diagnosis is a difficult challenge because such clients often have medical problems that require immediate attention. Detoxification may be necessary before clinical symptoms of disorders such as depression, anxiety, or schizophrenia are treated. Furthermore, clients with a dual diagnosis have a statistically greater propensity for violence, medication noncompliance, and failure to respond to treatment than do clients with a solitary diagnosis of mental illness or substance abuse. Clients are frequently hospitalized because they lack motivation to participate in treatment. Unfortunately, failure to respond to treatment also affects family members, friends, and co-workers (National Alliance for the Mentally Ill, 2006). Chapter 35 addresses issues of seriously and persistently mentally ill, homeless, or incarcerated clients.
This chapter reviews the two main etiologic theories associated with dual diagnosis and describes the
clinical symptoms and diagnostic characteristics. The chapter then focuses on the application of the nursing process to clients with a dual diagnosis.
clinical symptoms and diagnostic characteristics. The chapter then focuses on the application of the nursing process to clients with a dual diagnosis.
 Table 32.1 Prevalence of Substance-Related Disorders in Clients With a DSM-IV-TR Diagnosis | ||||||||||||||||||
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Etiology of Dual Diagnosis
The etiologies of substance-related disorders and different psychiatric disorders have been presented in other chapters. Two main theories have been proposed about the development of a dual diagnosis (Faltz & Callahan, 2002; Zahourek, 1996).
Vulnerability Model
The vulnerability model of dual diagnosis is based on the assumption that drug use causes a mental disorder. For example, daily marijuana use doubles the risk for psychosis; daily cocaine users have a seven times greater risk of a psychotic episode than nonusers; and dependence on alcohol doubles the risk of psychosis (Kosta, 2002; Miller, 1994; Miller, Eriksen, & Owley, 1994).
Attempts to identify what determines vulnerability are numerous. For example, alcoholic personality subtypes have been identified, and several personality traits have been described. They include emotional insecurity, anxiety, unsatisfied dependence needs, narcissism, externalization of blame, and the use of defense mechanisms such as denial.
Self-Medication Hypothesis
The self-medication hypothesis of dual diagnosis is based on the assumption that individuals with a psychiatric disorder use drugs to help them feel calmer or to alleviate clinical symptoms to achieve emotional homeostasis. Self-medication often leads to physical or psychological dependency on drugs or alcohol, creating a complex dual diagnosis problem (Kosta, 2002). For example, clients with schizophrenia self-medicate with alcohol or drugs to decrease anxiety (positive symptom) and the intensity of hallucinations (negative symptoms). Using substances does not result in the uncomfortable adverse effects of neuroleptic drugs, and to some degree is a socially accepted behavior. Table 32-2 lists seven major psychiatric disorders and shows how much each one increases an individual’s risk for substance-related disorders (National Mental Health Association, 2003).
 Table 32.2 Psychiatric Disorders and Increased Risk for Substance-Related Disorders | ||||||||||||||||||
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Clinical Symptoms and Diagnostic Characteristics
Clients with a dual diagnosis often are dissatisfied with life circumstances, have inadequate or ineffective support systems, live in a nontherapeutic home environment, and have a history of self-medication (National Alliance for the Mentally Ill, 2006; Zahourek, 1996).
The frequent use of drugs and alcohol interferes with the action of any psychiatric medications the client may be taking. Substance-related disorders often exacerbate clinical symptoms of an existing disorder or precipitate additional symptoms. Symptoms commonly seen include irritability, depression, sedation, hostility, aggression, delusions, hallucinations, poor impulse control, and suicidal or violent behavior. Lack of self-esteem and social skills contributes to disinterest in activities of daily living. Clients also have little interest in the future.
As noted earlier, many individuals are at risk for health problems, may have medical problems including acquired immunodeficiency syndrome (AIDS) or tuberculosis, are homeless, and are not motivated to receive treatment. If they do enter treatment, they often fail to keep scheduled appointments or follow through on referrals. Relapses and repeated institutionalizations are not uncommon. Several barriers to effective treatment have been identified. These are listed in Box 32-1.
Box 32.1: Barriers to Effective Treatment of Dual Diagnosis
Nature of substance-related disorder: The dually diagnosed (CAMI) client faces two options:
Continue with illicit drug of choice for brief moments of calmness, joy, and escape from problems, which can result in a decline in overall function and potentially increase the severity of psychiatric symptoms, or
Accept prescribed treatments to cease illicit drug use, which might include the use of medication to promote improved functioning and treatment outcome.
Countertransference:
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