Dual diagnosis
Encyclopedia
The term dual diagnosis is used to describe the comorbid condition of a person considered to be suffering from a mental illness
and a substance abuse
problem. There is considerable debate surrounding the appropriateness of the term being used to describe a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly, for example depression
and alcoholism
, or it can be restricted to specify severe mental illness (e.g. psychosis
, schizophrenia
) and substance misuse disorder (e.g. cannabis abuse), or a person who has a milder mental illness and a drug dependency, such as panic disorder
or generalized anxiety disorder and is dependent on opioids. Dual diagnosis is also a term used for people with an intellectual disability and diagnosed with a mental illness. Making a dual diagnosis in substance abusers is difficult as drug abuse itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance induced and pre-existing mental illness.
, anxiolytic, and antidepressant medications), Axis II conditions are typically considered more resistant or even refractory to such treatments.
Common Axis I conditions that may be treated though drug therapy, counseling, or a combination of the two include (but are not limited to) major depressive disorder, obsessive-compulsive disorder, generalized anxiety disorder, delusional disorder, and schizophrenia. Axis II conditions are limited to mental retardation and the personality disorders such as borderline personality
disorder and antisocial personality disorder
.
These conditions were originally separated from the Axis I conditions to highlight their intractability to treatment, although there is some evidence to suggest that personality disorders may be managed through long-term individual therapy. The fact that autistic disorder is coded on Axis I is one of the many criticisms of the DSM-IV-TR (the diagnostic manual for mental
disorders published by the American Psychiatric Association), as this falsely implies that austic disorder can be "cured" through popular but fad treatments.
Emerging literature has proved that dual diagnosis
has become a contemporary issue that require a multidimensional service delivery system in order to meet the needs of people with comorbidity conditions.(Regier,1990 and Hall,1996) agrees that “ It is a well-known, but poorly addressed fact that drug and alcohol problems often co-exist with mental disorders.”
The first treatment interventions and integrated treatment approach for people who had dual diagnosis began in 1984 in the New York State Office of Mental Health system (Sciacca, 1987, 1991, 1996). This began in an outpatient mental health clinic and expanded to a New York State-wide initiative. The MICAA training site for program and staff development New York State-wide was created specifically for
workforce development and program implementation across NY State. This initiative crossed systems to include substance abuse programs, homeless services, criminal justice services and more. It included
inpatient, outpatient and residential treatment. This initiative included clinical materials including
screening, assessment, outcome measures and treatment materials; curriculum and training materials; program development and implementation materials (Sciacca, 1990). This treatment approach, training curriculum and program implementation model was also adapted across systems in various states including Michigan (Sciacca, 1995 and Sciacca & Thompson, 1996). It included programs for the families of the dually diagnosed (Sciacca & Hatfield, 1995) and consumer led self-help programs (Sciacca, 1997). A specific curriculum served as an addendum to the SAMHSA-CMHS Managed Care Initiative Co-Occurring disorder report (Sciacca, 1998). Other states and cities who initiated this model include Tennessee, Alaska, Georgia, Kentucky, Washington DC, Dallas, Texas, among numerous others (Sciacca, 1995, 1997, 1998, 1999, 2001, 2003). In 1993 evidence based models including motivational interviewing, the stages of change and cognitive behavioral therapy correlates were integrated into the dual diagnosis treatment model and comprise the treatment approach and integrated care model that exists today (Sciacca, 1997, 2007, 2008, 2009, 2011).
However research has shown that there are only a few if any institutions that are geared to address the complex needs of people with dual diagnosis (Crawford, 2001). This brings the fact in agreement to Reisis discovery that despite the increase of dual diagnosis both in Australia and across the world; service distribution systems requires to be improved meet the needs of this group (Reiss, 1992).With this in mind
one would agree that this issue
has been historically neglected and there has been limited attention which has indirectly contributed to poor services to people with dual diagnosis (Allsop, 2008).
state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis
may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate alcohol sustained use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence. A protracted withdrawal syndrome can also occur with psychiatric and other symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use.
of dual diagnosis found that 47% of the people they worked with, who had schizophrenia, had a substance misuse disorder at some time in their life and that the chances of developing a substance misuse disorder was significantly higher among patients suffering from a psychotic illness than in the general population without a psychotic illness.
Another study looked at the extent of substance misuse in a group of 187 chronically mentally ill patients living in the community. According to the clinician's ratings, around a third of the sample used alcohol
, street drugs, or both during the six months before evaluation.
Further UK studies have shown slightly more moderate rates of substance misuse among mentally ill individuals. One study found that individuals suffering from schizophrenia showed just a 7% prevalence of problematic drug use in the year prior to being interviewed and 21% reported problematic use some time before that.
Wright and colleagues identified individuals with psychotic illnesses who had been in contact with services in the London
borough of Croydon
over the previous 6 months. Cases of alcohol or substance misuse and dependence were identified through standardized interviews
with clients and keyworkers.
Results showed that prevalence rates of dual diagnosis were 33% for the use of any substance, 20% for alcohol misuse only and 5% for drug misuse only. A lifetime history of any illicit drug
use was observed in 35% of the sample.
(of duration sufficient to allow for any substance-induced symptoms to dissipate).
However, principles do exist for successful treatment of individuals with coexisting mental and substance-abuse disorders. Treatment of the two disorders should be integrated, not separate, and should be a collaborative decision-making process between the treatment team and the patient. Recovery needs to be viewed as a marathon, not as a sprint, and methods and outcome goals should be explicit. Although many patients may reject medications as antithetical to substance-abuse recovery and side effects, they can be useful to reduce paranoia, anxiety, and craving. Medications that have proven effective include opioid replacement therapies, such as life-long maintenance on methadone or buprenorphine, to minimize risk of relapse, fatality, and legal trouble amongst opioid addicts, as well as helping with cravings, baclofen
for alcoholics, opioid addicts, cocaine addicts, and amphetamine addicts, to help eliminate drug cravings, and clozapine
, the first atypical antipsychotic
, which appears to reduce illicit drug use amongst stimulant addicts. Clozapine can cause respiratory arrest when combined with alcohol, benzodiazepines, or opioids, so it is not recommended to use in these groups.
theory suggests that certain types of substance abuse may causally lead to mental illness. Though causality in epidemiological studies can be difficult to establish, some evidence supporting a causal link between use of cannabis, and later development of psychosis
such as schizophrenia
exist.
This theory has been challenged as despite explosive increases in cannabis consumption over the past 40 years in western society, the rate of schizophrenia (and psychosis in general) has remained relatively stable.
For this theory to be correct, other factors which are thought to contribute to schizophrenia would have to have converged almost flawlessly to mask the effect of increased cannabis usage. However, increases in the incidence of bipolar disorder
, generalized anxiety disorder, and attention deficit-hyperactivity disorder have occurred nearly simultaneously with increases in cannabis use, mirroring rapid increase—though this could be due to a broadening of the diagnostic criteria for such disorders, and/or possibly a growing tendency to "medicalize" behavioral problems and deviance.
Statistics linking the incidence of schizophrenia and cannabis usage cannot ever demonstrate true causality or a lack of it (in a statistical sense, not in terms of causality as a theory on the causes of schizophrenia), however over long time periods with large samples, it appears exceedingly unlikely that cannabis usage could be causal in the development of schizophrenia. For this reason and because of the range of other viable theories regarding the causes of schizophrenia, studies claiming to show causality have tended to be met with caution by healthcare professionals.
suggests unnecessary exposure
to psychiatric medication alters neural synapses, introducing an imbalance that was not there before; withdraw the drug and the patient seems to do much worse, then seems to "recover" once returned to the drug or another one in the same class. It may appear as if the medication is working, when in fact
, it’s only treating a disorder that psychiatric medications created themselves. The disorders created by the use of psychiatric drugs resembles mental illness and substance abuse disorders in many cases. New exposure to psychiatric medication may lead to supersensitivity to the effects of drugs and alcohol
by accelerating the progression of addiction
making the problem worse.
theory suggests that people with severe mental illnesses misuse substances in order to relieve a specific set of symptoms and counter the negative side-effects of antipsychotic medication
.
Khantizan proposes that substances are not randomly chosen, but are specifically selected for their effects. For example, using stimulants such as nicotine
or amphetamine
s can be used to combat the sedation
that can be caused by higher doses of certain types of (usually typical
) antipsychotic medication. Conversely, some people taking medications with a stimulant
effect such as the SNRI
antidepressants Effexor (venlafaxine
) or Wellbutrin (bupropion
) may seek out benzodiazepines or opioid
narcotics to counter the anxiety
and insomnia
that such medications sometimes evoke.
Some studies show that nicotine administration can be effective for reducing motor side-effects of antipsychotics, with both bradykinesia (stiff muscles) and dyskinesia
(involuntary movement) being prevented.
theory suggests that people with severe mental illness commonly feel bad about themselves and that this makes them vulnerable to using psychoactive substances
to alleviate these feelings. Despite the existence of a wide range of dysphoric feelings (anxiety
, depression, boredom
, and loneliness
), the literature on self-reported reasons for use seems to lend support for the experience of these feelings being the primary motivator for drug and alcohol misuse.
, poverty
, lack of structured daily activity, lack of adult role responsibility, living in areas with high drug availability, and association with people who already misuse drugs.
Other evidence suggests that traumatic life events such as sexual abuse
, are associated with the development of psychiatric problems and substance abuse.
These interact with stressful life events and result in either a psychiatric disorder or trigger a relapse into an existing illness. The theory states that although anti-psychotic medication can reduce the vulnerability, substance abuse may increase it, causing the individual to be more likely to experience negative consequences from using relatively small amounts of substances.
These individuals therefore, are "supersensitive" to the effects of certain substances and suggest that individuals with psychotic illness such as schizophrenia may be less capable of sustaining moderate substance use over time without experiencing negative symptoms.
Although there are limitations in the research studies conducted in this area, namely that most have focused primarily on schizophrenia, this theory provides a good rationale as to why relatively low levels of substance misuse often result in negative consequences for individuals with severe mental illness.
Library of Congress, Producer, Sciacca Comprehensive Service Development for MIDAA, NY, NY.
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
and a substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
problem. There is considerable debate surrounding the appropriateness of the term being used to describe a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly, for example depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
and alcoholism
Alcoholism
Alcoholism is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the detriment of the drinker's health, personal relationships, and social standing...
, or it can be restricted to specify severe mental illness (e.g. psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
, schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
) and substance misuse disorder (e.g. cannabis abuse), or a person who has a milder mental illness and a drug dependency, such as panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
or generalized anxiety disorder and is dependent on opioids. Dual diagnosis is also a term used for people with an intellectual disability and diagnosed with a mental illness. Making a dual diagnosis in substance abusers is difficult as drug abuse itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance induced and pre-existing mental illness.
Overview
Dual Diagnoses have been neglected for a long time. Dual diagnosis is also used to describe a co-occurring condition in which a person is simultaneously diagnosed with an Axis I and an Axis II psychiatric disorder. While Axis I conditions are considered more or less amenable to treatments such as individual therapy and psychotropic drugs (e.g., antipsychoticAntipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
, anxiolytic, and antidepressant medications), Axis II conditions are typically considered more resistant or even refractory to such treatments.
Common Axis I conditions that may be treated though drug therapy, counseling, or a combination of the two include (but are not limited to) major depressive disorder, obsessive-compulsive disorder, generalized anxiety disorder, delusional disorder, and schizophrenia. Axis II conditions are limited to mental retardation and the personality disorders such as borderline personality
Personality
Personality is the particular combination of emotional, attitudinal, and behavioral response patterns of an individual.-Psychology:* Personality development, the concept that personality is affected by various sources* Personality disorder...
disorder and antisocial personality disorder
Antisocial personality disorder
Antisocial personality disorder is described by the American Psychiatric Association's Diagnostic and Statistical Manual, fourth edition , as an Axis II personality disorder characterized by "...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood...
.
These conditions were originally separated from the Axis I conditions to highlight their intractability to treatment, although there is some evidence to suggest that personality disorders may be managed through long-term individual therapy. The fact that autistic disorder is coded on Axis I is one of the many criticisms of the DSM-IV-TR (the diagnostic manual for mental
Mental
Mental, a word referring to aspects of, or things related to, the mind; or in anatomy, the skull, e.g. the mental foramen, can also mean:* a slang, pejorative term used to describe people who act like lunatics, which is itself an outdated term for people with mental disorders* Mental , a 2009...
disorders published by the American Psychiatric Association), as this falsely implies that austic disorder can be "cured" through popular but fad treatments.
Emerging literature has proved that dual diagnosis
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
has become a contemporary issue that require a multidimensional service delivery system in order to meet the needs of people with comorbidity conditions.(Regier,1990 and Hall,1996) agrees that “ It is a well-known, but poorly addressed fact that drug and alcohol problems often co-exist with mental disorders.”
The first treatment interventions and integrated treatment approach for people who had dual diagnosis began in 1984 in the New York State Office of Mental Health system (Sciacca, 1987, 1991, 1996). This began in an outpatient mental health clinic and expanded to a New York State-wide initiative. The MICAA training site for program and staff development New York State-wide was created specifically for
workforce development and program implementation across NY State. This initiative crossed systems to include substance abuse programs, homeless services, criminal justice services and more. It included
inpatient, outpatient and residential treatment. This initiative included clinical materials including
screening, assessment, outcome measures and treatment materials; curriculum and training materials; program development and implementation materials (Sciacca, 1990). This treatment approach, training curriculum and program implementation model was also adapted across systems in various states including Michigan (Sciacca, 1995 and Sciacca & Thompson, 1996). It included programs for the families of the dually diagnosed (Sciacca & Hatfield, 1995) and consumer led self-help programs (Sciacca, 1997). A specific curriculum served as an addendum to the SAMHSA-CMHS Managed Care Initiative Co-Occurring disorder report (Sciacca, 1998). Other states and cities who initiated this model include Tennessee, Alaska, Georgia, Kentucky, Washington DC, Dallas, Texas, among numerous others (Sciacca, 1995, 1997, 1998, 1999, 2001, 2003). In 1993 evidence based models including motivational interviewing, the stages of change and cognitive behavioral therapy correlates were integrated into the dual diagnosis treatment model and comprise the treatment approach and integrated care model that exists today (Sciacca, 1997, 2007, 2008, 2009, 2011).
However research has shown that there are only a few if any institutions that are geared to address the complex needs of people with dual diagnosis (Crawford, 2001). This brings the fact in agreement to Reisis discovery that despite the increase of dual diagnosis both in Australia and across the world; service distribution systems requires to be improved meet the needs of this group (Reiss, 1992).With this in mind
Mind
The concept of mind is understood in many different ways by many different traditions, ranging from panpsychism and animism to traditional and organized religious views, as well as secular and materialist philosophies. Most agree that minds are constituted by conscious experience and intelligent...
one would agree that this issue
Issue
Issue may refer to:* Issue , a monthly Korean comics anthology magazine* Issues, a Jewish magazine published by the American Council for Judaism* Issue , a unit of work to accomplish an improvement in a data system...
has been historically neglected and there has been limited attention which has indirectly contributed to poor services to people with dual diagnosis (Allsop, 2008).
Differentiating pre-existing and substance induced
Drug abuse, including alcohol and prescription drugs can induce symptomatology which resembles mental illness which can make it difficult to differentiate between substance induced psychiatric syndromes and pre-existing mental health problems. More often than not psychiatric disorders among drug or alcohol abusers disappear with prolonged abstinence. Substance induced psychiatric symptoms can occur both in the intoxicated state and also during the withdrawalWithdrawal
Withdrawal can refer to any sort of separation, but is most commonly used to describe the group of symptoms that occurs upon the abrupt discontinuation/separation or a decrease in dosage of the intake of medications, recreational drugs, and alcohol...
state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis
Cannabis
Cannabis is a genus of flowering plants that includes three putative species, Cannabis sativa, Cannabis indica, and Cannabis ruderalis. These three taxa are indigenous to Central Asia, and South Asia. Cannabis has long been used for fibre , for seed and seed oils, for medicinal purposes, and as a...
may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate alcohol sustained use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence. A protracted withdrawal syndrome can also occur with psychiatric and other symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use.
Prevalence
One US study attempting to assess the prevalencePrevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
of dual diagnosis found that 47% of the people they worked with, who had schizophrenia, had a substance misuse disorder at some time in their life and that the chances of developing a substance misuse disorder was significantly higher among patients suffering from a psychotic illness than in the general population without a psychotic illness.
Another study looked at the extent of substance misuse in a group of 187 chronically mentally ill patients living in the community. According to the clinician's ratings, around a third of the sample used alcohol
Alcoholic beverage
An alcoholic beverage is a drink containing ethanol, commonly known as alcohol. Alcoholic beverages are divided into three general classes: beers, wines, and spirits. They are legally consumed in most countries, and over 100 countries have laws regulating their production, sale, and consumption...
, street drugs, or both during the six months before evaluation.
Further UK studies have shown slightly more moderate rates of substance misuse among mentally ill individuals. One study found that individuals suffering from schizophrenia showed just a 7% prevalence of problematic drug use in the year prior to being interviewed and 21% reported problematic use some time before that.
Wright and colleagues identified individuals with psychotic illnesses who had been in contact with services in the London
London
London is the capital city of :England and the :United Kingdom, the largest metropolitan area in the United Kingdom, and the largest urban zone in the European Union by most measures. Located on the River Thames, London has been a major settlement for two millennia, its history going back to its...
borough of Croydon
Croydon
Croydon is a town in South London, England, located within the London Borough of Croydon to which it gives its name. It is situated south of Charing Cross...
over the previous 6 months. Cases of alcohol or substance misuse and dependence were identified through standardized interviews
Structured interview
A structured interview is a quantitative research method commonly employed in survey research. The aim of this approach is to ensure that each interview is presented with exactly the same questions in the same order...
with clients and keyworkers.
Results showed that prevalence rates of dual diagnosis were 33% for the use of any substance, 20% for alcohol misuse only and 5% for drug misuse only. A lifetime history of any illicit drug
Illegal drug trade
The illegal drug trade is a global black market, dedicated to cultivation, manufacture, distribution and sale of those substances which are subject to drug prohibition laws. Most jurisdictions prohibit trade, except under license, of many types of drugs by drug prohibition laws.A UN report said the...
use was observed in 35% of the sample.
Diagnosis
Substance use disorders can be confused with other psychiatric disease. There are diagnoses for substance-induced mood disorders and substance-induced anxiety disorders and thus such overlap can be complicated. For this reason, the DSM-IV advises that diagnoses of primary psychiatric disorders not be made in the absence of sobrietySobriety
Sobriety is the condition of not having any measurable levels, or effects from, alcohol or other drugs that alter ones mood or behaviors. According to WHO "Lexicon of alcohol and drug terms..." sobriety is continued abstinence from alcohol and psychoactive drug use...
(of duration sufficient to allow for any substance-induced symptoms to dissipate).
Treatment
It can be very difficult to find appropriate treatment opportunities for these people. Most substance-abuse centers do not accept people with serious psychiatric conditions, and many psychiatric centers do not have expertise with substance abuse.However, principles do exist for successful treatment of individuals with coexisting mental and substance-abuse disorders. Treatment of the two disorders should be integrated, not separate, and should be a collaborative decision-making process between the treatment team and the patient. Recovery needs to be viewed as a marathon, not as a sprint, and methods and outcome goals should be explicit. Although many patients may reject medications as antithetical to substance-abuse recovery and side effects, they can be useful to reduce paranoia, anxiety, and craving. Medications that have proven effective include opioid replacement therapies, such as life-long maintenance on methadone or buprenorphine, to minimize risk of relapse, fatality, and legal trouble amongst opioid addicts, as well as helping with cravings, baclofen
Baclofen
Baclofen is a derivative of gamma-aminobutyric acid . It is primarily used to treat spasticity and is under investigation for the treatment of alcoholism....
for alcoholics, opioid addicts, cocaine addicts, and amphetamine addicts, to help eliminate drug cravings, and clozapine
Clozapine
Clozapine is an antipsychotic medication used in the treatment of schizophrenia, and is also used off-label in the treatment of bipolar disorder. Wyatt. R and Chew...
, the first atypical antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
, which appears to reduce illicit drug use amongst stimulant addicts. Clozapine can cause respiratory arrest when combined with alcohol, benzodiazepines, or opioids, so it is not recommended to use in these groups.
Theories of dual diagnosis
A number of theories to explain the relationship between mental illness and substance abuse exist. Mueser et al. have identified several theories that attempt to explain the mental illness-substance misuse relationship.Causality
The causalityCausality
Causality is the relationship between an event and a second event , where the second event is understood as a consequence of the first....
theory suggests that certain types of substance abuse may causally lead to mental illness. Though causality in epidemiological studies can be difficult to establish, some evidence supporting a causal link between use of cannabis, and later development of psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
such as schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
exist.
This theory has been challenged as despite explosive increases in cannabis consumption over the past 40 years in western society, the rate of schizophrenia (and psychosis in general) has remained relatively stable.
For this theory to be correct, other factors which are thought to contribute to schizophrenia would have to have converged almost flawlessly to mask the effect of increased cannabis usage. However, increases in the incidence of bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
, generalized anxiety disorder, and attention deficit-hyperactivity disorder have occurred nearly simultaneously with increases in cannabis use, mirroring rapid increase—though this could be due to a broadening of the diagnostic criteria for such disorders, and/or possibly a growing tendency to "medicalize" behavioral problems and deviance.
Statistics linking the incidence of schizophrenia and cannabis usage cannot ever demonstrate true causality or a lack of it (in a statistical sense, not in terms of causality as a theory on the causes of schizophrenia), however over long time periods with large samples, it appears exceedingly unlikely that cannabis usage could be causal in the development of schizophrenia. For this reason and because of the range of other viable theories regarding the causes of schizophrenia, studies claiming to show causality have tended to be met with caution by healthcare professionals.
Past exposure to psychiatric medications theory
The Past-exposure theoryTheory
The English word theory was derived from a technical term in Ancient Greek philosophy. The word theoria, , meant "a looking at, viewing, beholding", and referring to contemplation or speculation, as opposed to action...
suggests unnecessary exposure
Exposure
-Entertainment:* Exposure , the practice of revealing the secrets of magic to non-magicians* Exposure , a short film anthology series on Sci-Fi Channel from 2000–2002* Exposure , a current affairs strand on ITV in 2011...
to psychiatric medication alters neural synapses, introducing an imbalance that was not there before; withdraw the drug and the patient seems to do much worse, then seems to "recover" once returned to the drug or another one in the same class. It may appear as if the medication is working, when in fact
Fact
A fact is something that has really occurred or is actually the case. The usual test for a statement of fact is verifiability, that is whether it can be shown to correspond to experience. Standard reference works are often used to check facts...
, it’s only treating a disorder that psychiatric medications created themselves. The disorders created by the use of psychiatric drugs resembles mental illness and substance abuse disorders in many cases. New exposure to psychiatric medication may lead to supersensitivity to the effects of drugs and alcohol
Alcohol
In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....
by accelerating the progression of addiction
Addiction
Historically, addiction has been defined as physical and psychological dependence on psychoactive substances which cross the blood-brain barrier once ingested, temporarily altering the chemical milieu of the brain.Addiction can also be viewed as a continued involvement with a substance or activity...
making the problem worse.
Self-medication theory
The self-medicationSelf-medication
Self-medication is a term used to describe the use of drugs or other self-soothing forms of behavior to treat untreated and often undiagnosed mental distress, stress and anxiety, including mental illnesses and/or psychological trauma...
theory suggests that people with severe mental illnesses misuse substances in order to relieve a specific set of symptoms and counter the negative side-effects of antipsychotic medication
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
.
Khantizan proposes that substances are not randomly chosen, but are specifically selected for their effects. For example, using stimulants such as nicotine
Nicotine
Nicotine is an alkaloid found in the nightshade family of plants that constitutes approximately 0.6–3.0% of the dry weight of tobacco, with biosynthesis taking place in the roots and accumulation occurring in the leaves...
or amphetamine
Amphetamine
Amphetamine or amfetamine is a psychostimulant drug of the phenethylamine class which produces increased wakefulness and focus in association with decreased fatigue and appetite.Brand names of medications that contain, or metabolize into, amphetamine include Adderall, Dexedrine, Dextrostat,...
s can be used to combat the sedation
Sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure...
that can be caused by higher doses of certain types of (usually typical
Typical antipsychotic
Typical antipsychotics are a class of antipsychotic drugs first developed in the 1950s and used to treat psychosis...
) antipsychotic medication. Conversely, some people taking medications with a stimulant
Stimulant
Stimulants are psychoactive drugs which induce temporary improvements in either mental or physical function or both. Examples of these kinds of effects may include enhanced alertness, wakefulness, and locomotion, among others...
effect such as the SNRI
Serotonin-norepinephrine reuptake inhibitor
Serotonin–norepinephrine reuptake inhibitors are a class of antidepressant drugs used in the treatment of major depression and other mood disorders...
antidepressants Effexor (venlafaxine
Venlafaxine
Venlafaxine is an antidepressant of the serotonin-norepinephrine reuptake inhibitor class. First introduced by Wyeth in 1993, now marketed by Pfizer, it is licensed for the treatment of major depressive disorder , as a treatment for generalized anxiety disorder, and comorbid indications in...
) or Wellbutrin (bupropion
Bupropion
Bupropion is an atypical antidepressant and smoking cessation aid. The drug is a non-tricyclic antidepressant and differs from most commonly prescribed antidepressants such as SSRIs, as its primary pharmacological action is thought to be norepinephrine-dopamine reuptake inhibition...
) may seek out benzodiazepines or opioid
Opioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
narcotics to counter the anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
and insomnia
Insomnia
Insomnia is most often defined by an individual's report of sleeping difficulties. While the term is sometimes used in sleep literature to describe a disorder demonstrated by polysomnographic evidence of disturbed sleep, insomnia is often defined as a positive response to either of two questions:...
that such medications sometimes evoke.
Some studies show that nicotine administration can be effective for reducing motor side-effects of antipsychotics, with both bradykinesia (stiff muscles) and dyskinesia
Dyskinesia
Dyskinesia is a movement disorder which consists of effects including diminished voluntary movements and the presence of involuntary movements, similar to tics or choreia. Dyskinesia can be anything from a slight tremor of the hands to uncontrollable movement of, most commonly, the upper body but...
(involuntary movement) being prevented.
Alleviation of dysphoria theory
The alleviation of dysphoriaDysphoria
Dysphoria is medically recognized as a mental and emotional condition in which a person experiences intense feelings of depression, discontent and indifference to the world around them.Mood disorders can induce dysphoria, often with a heightened risk of suicide, especially in...
theory suggests that people with severe mental illness commonly feel bad about themselves and that this makes them vulnerable to using psychoactive substances
Psychoactive drug
A psychoactive drug, psychopharmaceutical, or psychotropic is a chemical substance that crosses the blood–brain barrier and acts primarily upon the central nervous system where it affects brain function, resulting in changes in perception, mood, consciousness, cognition, and behavior...
to alleviate these feelings. Despite the existence of a wide range of dysphoric feelings (anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
, depression, boredom
Boredom
Boredom is an emotional state experienced when an individual is without any activity or is not interested in their surroundings. The first recorded use of the word boredom is in the novel Bleak House by Charles Dickens, written in 1852, in which it appears six times, although the expression to be a...
, and loneliness
Loneliness
Loneliness is an unpleasant feeling in which a person feels a strong sense of emptiness and solitude resulting from inadequate levels of social relationships. However, it is a subjective experience...
), the literature on self-reported reasons for use seems to lend support for the experience of these feelings being the primary motivator for drug and alcohol misuse.
Multiple risk factor theory
Another theory is that there may be risk factors that can lead to both substance abuse and mental illness. Mueser hypothesizes that these may include factors such as social isolationSocial isolation
Social isolation refers to a lack of contact with society for members of social species. There may be many causes and individuals in numerous generally social species are isolated at times, it need not be a pathological condition. In human society, in those cases where it is viewed as a pathology,...
, poverty
Poverty
Poverty is the lack of a certain amount of material possessions or money. Absolute poverty or destitution is inability to afford basic human needs, which commonly includes clean and fresh water, nutrition, health care, education, clothing and shelter. About 1.7 billion people are estimated to live...
, lack of structured daily activity, lack of adult role responsibility, living in areas with high drug availability, and association with people who already misuse drugs.
Other evidence suggests that traumatic life events such as sexual abuse
Abuse
Abuse is the improper usage or treatment for a bad purpose, often to unfairly or improperly gain benefit. Abuse can come in many forms, such as: physical or verbal maltreatment, injury, sexual assault, violation, rape, unjust practices; wrongful practice or custom; offense; crime, or otherwise...
, are associated with the development of psychiatric problems and substance abuse.
The supersensitivity theory
The supersensitivity theory proposes that certain individuals who have severe mental illness also have biological and psychological vulnerabilities, caused by genetic and early environmental life events.These interact with stressful life events and result in either a psychiatric disorder or trigger a relapse into an existing illness. The theory states that although anti-psychotic medication can reduce the vulnerability, substance abuse may increase it, causing the individual to be more likely to experience negative consequences from using relatively small amounts of substances.
These individuals therefore, are "supersensitive" to the effects of certain substances and suggest that individuals with psychotic illness such as schizophrenia may be less capable of sustaining moderate substance use over time without experiencing negative symptoms.
Although there are limitations in the research studies conducted in this area, namely that most have focused primarily on schizophrenia, this theory provides a good rationale as to why relatively low levels of substance misuse often result in negative consequences for individuals with severe mental illness.
Footnotes
- Sciacca, K., 1987 "New Initiatives in the Treatment of the Chronic Patient with Alcohol /Substance Use Problems" TIE-Lines, Published by the Information Exchange on Young Adult Chronic Patients |Volume=1V |issue=3, month=July,1987.
- Sciacca, K., 1990-2010, "MIDAA SERVICE MANUAL: A Step by Step Guide to Program Implementation and Comprehensive Services for Dual/Multiple Disorders" Publisher, Sciacca Comprehensive Service Development for MIDAA, New York, NY -manual.
- Sciacca, K. 1991 "An Integrated Treatment Approach for Severely Mentally Ill Individuals with Substance Disorders" New Directions for Mental Health Services, Dual Diagnosis of Major Mental Illness and Substance Disorders, Jossey-Bass, publishers, volume #50 summer 1991. http://www.scribd.com/doc/17222783/An-Integrated-Treatment-Approach-for-Severely-Mentally-Ill-Individuals-With-Substance-Disorders
- Sciacca, K., Hatfield, A.B., 1995 "The Family and the Dually Diagnosed Patient" Double Jeopardy, Eds. Lehman, A.F., and Dixon, L.B., Harwood Academic Publishers, Chapter 12, pages 193-209. http://www.scribd.com/doc/17222954/The-Family-and-the-Dually-Diagnosed-Patient
- Sciacca,K., 1995 "Integrated Treatment for MIDAA: The Alaska Example" Video. Included in the
Library of Congress, Producer, Sciacca Comprehensive Service Development for MIDAA, NY, NY.
- Sciacca, K., and Thompson, C. M., 1996 "Program Development and Integrated Treatment Across Systems for Dual Diagnosis: Mental Illness, Drug Addiction and Alcoholism MIDAA" The Journal of Mental Health Administration, Volume=23, issue=3, Summer 1996, pages 288-297. http://www.scribd.com/doc/17223077/Program-Development-and-Integrated-Treatment-Across-Systems-for-Dual-Diagnosis
- Sciacca, K., 1996. "On Co-occurring Addictive and Mental Disorders: A Brief History of the Origins of Dual Diagnosis Treatment and Program Development" American Journal of Orthopsychiatry. Volume 66, |issue #3, July 1996. http://www.scribd.com/doc/16684317/On-Cooccurring-Addictive-Mental-Disorders-a-Brief-History-Kathleen-Sciacca
- Sciacca, K., 1997 "Peer Support for People Challenged by Dual Diagnosis: Helpful People In Touch" Consumers as Providers in Psychosocial Rehabilitation, Eds. Mowbray, C.T., Moxley, D.P., Jasper, C.A., Howell, L.L., publisher=IAPSRS, Chapter 6, |pages 82-. http://motivationalinterviewingtraining.com/uploads/scan_1_HelpfullPeopleInTouchChapt..pdf
- Sciacca, K., 1997 "Removing Barriers: Dual Diagnosis Treatment and Motivational Interviewing" Professional Counselor, Volume 12, issue #1, February 1997, pages 41-46. http://www.scribd.com/doc/16682858/Removing-Barriers-Dual-Diagnosis-Treatment-and-Motivational-Interviewing-Kathleen-Sciacca
- Sciacca, K., 1997 "Cross-Training Yields Continuity in Dual-Diagnosis Programs" Mental Health Weekly Volume 7, issue 21, Page 6, publisher=Manisses, Providence, RI.
- Sciacca, K., 1998 "Curriculum for MICAA and CAMI Direct Care Providers: Mental Illness, Drug Addiction and Alcoholism MIDAA(R): Training, Cross-Training and Program Development" Published Report, SAMHSA-CMHS Managed Care Initiative Co-Occurring Disorder Report: Co-Occurring Psychiatric and Substance Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies and Training Curricula, Substance Abuse Mental Health Services Administration, 1998. http://www.scribd.com/doc/17273611/CurriculumSAMHSAreport1997Workforce-Competencies-Dual-diagnosis-cooccurring-mental-illness-drug-addiction-alcoholism-Kathleen-Sciacca
- Sciacca, K., 1998 "Tennessee Initiates State-wide Dual Diagnosis Program Development" Alcoholism and Drug Abuse Weekly, |Volume 10, issue 7, Page 5, publisher=Manisses Pub. Providence, RI.
- Sciacca, K., 1999 "D.C. Reports Progress with Dual Diagnosis Integration Initiative" Alcoholism and Drug Abuse Weekly, Volume 11, Issue 41, Page 5, Manisses Pub. Providence, RI.
- Sciacca, K., 2001 "Theme-Centered Interactional (TCI) Group Leading and the Workshop Institute for Living-Learning W.I.L.L, An Overview" MINT Bulletin, Volume 8, issue 2.
- Sciacca, K., Dobbins, K., 2001 "Kentucky Dual Diagnosis Residence Yields Remarkable Outcome" |Mental Health Weekly, volume 11, issue 7, page 5, Manisses Pub. Providence, RI.
- Sciacca, K., 2007 "Dual Diagnosis Treatment and Motivational Interviewing for Co-occurring Disorders" National Council Magazine, Volume 2, pages 22-23. http://www.scribd.com/doc/17222545/Dual-Diagnosis-Treatment-and-Motivational-Interviewing-for-Cooccurring-Disorders-Kathleen-Sciacca
- Sciacca. K., 2008 "The Impact of Motivational Interviewing in the Field of Dual/Multiple Disorders of Co-occurring Mental Illness, Drug Addiction and Alcoholism" MINT Bulletin, volume=14, issue=2.
- Sciacca, K., 2009 "Best Practices for Dual Diagnosis Treatment and Program Development: Co-occurring Mental Illness and Substance Disorders in Various Combinations" The Praeger International Collection on Addictions, Editor, Angela Brown-Miller, volume 3, chapter 9, pages 161-188, Praeger, Westport, CT. London. http://www.scribd.com/doc/21801032/BestPracticesForDualDiagnosisTreatment-ProgramDevelopment-Co-occurring-Mental-Illness-Substance-Disorders-KSciacca2009
- Sciacca, K., 2009 "Motivational Interviewing Glossary & Fact Sheet" Copyright, Kathleen Sciacca,NYC. http://www.scribd.com/doc/19629380/Motivational-Interviewing-Glossary-Fact-Sheet-KSciacca-September09
- Sciacca, K., 2009 "Dual Diagnosis Fact Sheet" Copyright, Kathleen Sciacca Collective works NYC. http://www.scribd.com/doc/17483620/DualDiagnosisFactSheetKSciacca2-Cooccurring-mental-illness-and-substance-disorders
- Sciacca K., 2011 "Integrated Group Treatment for People Experiencing Mental Health –Substance Use Problems" Intervention in Mental Health-Substance Use, Editor, David B. Cooper, Chapter 9. Pages 114-127, Radcliffe Publishing, London, New York. http://www.scribd.com/doc/52145406/Integrated-Group-Treatment-for-People-experiencing-Mental-Health-Substance-Use-Problems-Kathleen-Sciacca
External references
- Sciacca, K., 1987 "New Initiatives in the Treatment of the Chronic Patient with Alcohol /Substance Use Problems" TIE-Lines, Published by the Information Exchange on Young Adult Chronic Patients |Volume=1V |issue=3, month=July,1987.
- Sciacca, K. 1991 "An Integrated Treatment Approach for Severely Mentally Ill Individuals with Substance Disorders" New Directions for Mental Health Services, Dual Diagnosis of Major Mental Illness and Substance Disorders, Jossey-Bass, publishers, volume #50 summer 1991. http://www.scribd.com/doc/17222783/An-Integrated-Treatment-Approach-for-Severely-Mentally-Ill-Individuals-With-Substance-Disorders
- Sciacca, K., Hatfield, A.B., 1995 "The Family and the Dually Diagnosed Patient" Double Jeopardy, Eds. Lehman, A.F., and Dixon, L.B., Harwood Academic Publishers, Chapter 12, pages 193-209. http://www.scribd.com/doc/17222954/The-Family-and-the-Dually-Diagnosed-Patient
- Sciacca, K., and Thompson, C. M., 1996 "Program Development and Integrated Treatment Across Systems for Dual Diagnosis: Mental Illness, Drug Addiction and Alcoholism MIDAA" The Journal of Mental Health Administration, Volume=23, issue=3, Summer 1996, pages 288-297. http://www.scribd.com/doc/17223077/Program-Development-and-Integrated-Treatment-Across-Systems-for-Dual-Diagnosis
- Sciacca, K., 1996. "On Co-occurring Addictive and Mental Disorders: A Brief History of the Origins of Dual Diagnosis Treatment and Program Development" American Journal of Orthopsychiatry. Volume 66, |issue #3, July 1996. http://www.scribd.com/doc/16684317/On-Cooccurring-Addictive-Mental-Disorders-a-Brief-History-Kathleen-Sciacca
- Sciacca, K., 1997 "Peer Support for People Challenged by Dual Diagnosis: Helpful People In Touch" Consumers as Providers in Psychosocial Rehabilitation, Eds. Mowbray, C.T., Moxley, D.P., Jasper, C.A., Howell, L.L., publisher=IAPSRS, Chapter 6, |pages 82-. http://motivationalinterviewingtraining.com/uploads/scan_1_HelpfullPeopleInTouchChapt..pdf
- Sciacca, K., 1997 "Removing Barriers: Dual Diagnosis Treatment and Motivational Interviewing" Professional Counselor, Volume 12, issue #1, February 1997, pages 41-46. http://www.scribd.com/doc/16682858/Removing-Barriers-Dual-Diagnosis-Treatment-and-Motivational-Interviewing-Kathleen-Sciacca
- Sciacca, K., 1997 "Cross-Training Yields Continuity in Dual-Diagnosis Programs" Mental Health Weekly Volume 7, issue 21, Page 6, publisher=Manisses, Providence, RI.
- Sciacca, K., 1998 "Curriculum for MICAA and CAMI Direct Care Providers: Mental Illness, Drug Addiction and Alcoholism MIDAA(R): Training, Cross-Training and Program Development" Published Report, SAMHSA-CMHS Managed Care Initiative Co-Occurring Disorder Report: Co-Occurring Psychiatric and Substance Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies and Training Curricula, Substance Abuse Mental Health Services Administration, 1998. http://www.scribd.com/doc/17273611/CurriculumSAMHSAreport1997Workforce-Competencies-Dual-diagnosis-cooccurring-mental-illness-drug-addiction-alcoholism-Kathleen-Sciacca
- Sciacca, K., 1998 "Tennessee Initiates State-wide Dual Diagnosis Program Development" Alcoholism and Drug Abuse Weekly, |Volume 10, issue 7, Page 5, publisher=Manisses Pub. Providence, RI.
- Sciacca, K., 1999 "D.C. Reports Progress with Dual Diagnosis Integration Initiative" Alcoholism and Drug Abuse Weekly, Volume 11, Issue 41, Page 5, Manisses Pub. Providence, RI.
- Sciacca, K., 2001 "Theme-Centered Interactional (TCI) Group Leading and the Workshop Institute for Living-Learning W.I.L.L, An Overview" MINT Bulletin, Volume 8, issue 2.
- Sciacca, K., Dobbins, K., 2001 "Kentucky Dual Diagnosis Residence Yields Remarkable Outcome" |Mental Health Weekly, volume 11, issue 7, page 5, Manisses Pub. Providence, RI.
- Sciacca, K., 2007 "Dual Diagnosis Treatment and Motivational Interviewing for Co-occurring Disorders" National Council Magazine, Volume 2, pages 22-23. http://www.scribd.com/doc/17222545/Dual-Diagnosis-Treatment-and-Motivational-Interviewing-for-Cooccurring-Disorders-Kathleen-Sciacca
- Sciacca. K., 2008 "The Impact of Motivational Interviewing in the Field of Dual/Multiple Disorders of Co-occurring Mental Illness, Drug Addiction and Alcoholism" MINT Bulletin, volume=14, issue=2.
- Sciacca, K., 2009 "Best Practices for Dual Diagnosis Treatment and Program Development: Co-occurring Mental Illness and Substance Disorders in Various Combinations" The Praeger International Collection on Addictions, Editor, Angela Brown-Miller, volume 3, chapter 9, pages 161-188, Praeger, Westport, CT. London. http://www.scribd.com/doc/21801032/BestPracticesForDualDiagnosisTreatment-ProgramDevelopment-Co-occurring-Mental-Illness-Substance-Disorders-KSciacca2009
- Sciacca, K., 2009 "Motivational Interviewing Glossary & Fact Sheet" Copyright, Kathleen Sciacca,NYC. http://www.scribd.com/doc/19629380/Motivational-Interviewing-Glossary-Fact-Sheet-KSciacca-September09
- Sciacca, K., 2009 "Dual Diagnosis Fact Sheet" Copyright, Kathleen Sciacca Collective works NYC. http://www.scribd.com/doc/17483620/DualDiagnosisFactSheetKSciacca2-Cooccurring-mental-illness-and-substance-disorders
- Sciacca K., 2011 "Integrated Group Treatment for People Experiencing Mental Health –Substance Use Problems" Intervention in Mental Health-Substance Use, Editor, David B. Cooper, Chapter 9. Pages 114-127, Radcliffe Publishing, London, New York. http://www.scribd.com/doc/52145406/Integrated-Group-Treatment-for-People-experiencing-Mental-Health-Substance-Use-Problems-Kathleen-Sciacca