Dual disorders pathology

10 basic points on Dual Pathology: addiction and other mental illness

1. Dual Pathology
2. Comorbidity in Psychiatry
3. Dual pathology from substance induced disorders
4. How common are Dual Pathology disorders?
5. Common factors
6. Is it possible to explain complex mental and behavioral disorders as dual
7. pathology?
8. New addictions paradigm
9. How can dual pathology be diagnosed?
10. How shall Dual Pathology be treated?
11. Why is there still some reluctance to the concept of Dual Pathology?

1 What is Dual Pathology: Addiction and other Mental illness?

Most people with an addictive disorder are also diagnosed with mental disorders and vice versa. A number of different terms have been applied to refer to the vast population of patients with both an addictive disorder and another mental illness, including comorbidity, dual diagnosis, dual disorders, mentally ill chemical abusers, chemically addicted mentally ill, co-occurring disorder, or comorbid disorder. However, the operational definitions of these different terms vary significantly and vary within distinct clinical and social settings. Furthermore, these terms have different connotations, and some of them have been applied to diverse groups of patients with a variety of two or more coexisting conditions such as learning disability and mental health problems, personality disorder with an additional psychiatric illness, or sexual dysfunction and an associated mental disorder. To address this terminology conundrum, this World Psychiatric Association(WPA) Section proposes and, therefore, has chosen to use the term ‘dual pathology’.

Contents

• 10 basic points on Dual Pathology addiction and other mental illness
• 1 What is Dual Pathology Addiction and other Mental illness
• 2 Comorbidity in Psychiatry
• 3 How to distinguish dual pathology from substance induced disorders
• 4 How common are Dual Pathology disorders
• References

It is also important to clarify that the concept of duality does not solely refers to the existence of two disorders in a given patient, but rather to the presence of at least one addictive disorder with at least another mental disorder.

A report released by the Institute of Medicine (US) on 2006 emphasizes the need to improve services for “co-occurring” mental health/substance use problems and one component of this effort is increased understanding of the etiologic relationship between substance use disorders and other psychiatric disorders.

A new approach is needed to enable clinicians, researchers and managers to offer adequate assessment and evidence-based treatments to patients with dual pathology, who cannot be adequately and efficiently managed by cross-referral between psychiatric and addiction services as currently configured and resourced.

A report released by the Institute of Medicine (US) on 2006 emphasizes the need to improve services for “co-occurring” mental health/substance use problems and one component of this effort is increased understanding of the etiologic relationship between substance use disorders and other psychiatric disorders.

A new approach is needed to enable clinicians, researchers and managers to offer adequate assessment and evidence-based treatments to patients with dual pathology, who cannot be adequately and efficiently managed by cross-referral between psychiatric and addiction services as currently configured and resourced.

2 Comorbidity in Psychiatry

Current nosological approach does not provide a framework for internal (sub-threshold symptoms) or external (comorbidity) heterogeneity of the different diagnostic categories. The prevailing “Neo-Kraepelinian” diagnostic system solely accounts for a categorical diagnosis, therefore not allowing for the possibility of dual diagnosis. There has been substantial criticism to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), due to problems of diagnostic overlap, lack of clear boundaries between normality and disease, a failure to take into account findings from novel research and the lack of diagnostic stability over time

3 How to distinguish dual pathology from substance induced disorders?

The identification of substance-induced versus independent psychiatric symptoms or disorders has important treatment implications and often constitutes a challenge in daily clinical practice. Similar patterns of comorbidity and risk factors in individuals with substance induced disorder and those with independent non-substance induced psychiatric symptoms suggest that the two conditions may share underlying etiologic factors

Prospective epidemiological studies do not support the hypotheses that comorbidity of substance use disorders with other psychiatric illnesses is primarily a consequence of substance abuse or dependence or that increasing comorbidity is largely attributable to increasing use of substances. Yet emphasis is often on the effects of substances on the brain creating the impression that dual disorders are a natural consequence of these substances. However addictive drugs or exposure to gambling will not lead to addictive behaviors or drug dependence in most individuals but only in vulnerable ones, although, according to some researchers, neuroadaptation or regulation of neuronal plasticity, and molecular changes, may alter gene expression in some cases and subsequently lead to substance use disorders.

Research instruments are also often insufficiently sensitive to discriminate between independent, true dual pathology, and substance-induced symptoms. Structured instruments, as Global Appraisal of Individual Needs - Short Screener-GAIN-SS and Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV-PRISM, have been developed to increase the diagnostic validity. While structured instruments can help organize diagnostic information, clinicians must still make judgments on the origin of symptoms.

4 How common are Dual Pathology disorders?

Comorbidity of addictive disorders and other psychiatric disorders, i.e., dual disorders, is very common and a large body of literature has accumulated demonstrating that mental disorders are strongly associated with substance use disorders.

The inclusion of behavioral addictions like pathological gambling must change our way of understanding and dealing with addictions. Pathological (disordered) gambling has commonalities in clinical expression, etiology, comorbidity, physiology and treatment with substance use disorders (DSM-5). A challenge is to understand the development of compulsivity at a neurochemical level not only for drugs.