Dual Diagnosis Therapy

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Dual Diagnosis Therapy

Reflections - Addiction Therapy

Dual diagnosis (also called co-occurring disorders, COD) is the condition of suffering from a mental illness and a comorbid substance abuse problem. There is considerable debate surrounding the appropriateness of using a single category for 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. Diagnosing a primary psychiatric illness in substance abusers is challenging as drug abuse itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance induced and pre-existing mental illness.


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Dual diagnosis is the combination of a substance abuse/dependence disorder and a mental health diagnosis, such as depression, anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, bipolar disorder, unresolved grief and loss, trauma, etc. Substance abuse coupled with dual diagnosis issues can cause clients to slip into psychosis, depression, paranoid behaviors, etc,; and Reflections Recovery Program works closely with each client in dual diagnosis treatment to determine whether one truly has a dual diagnosis issue and how to best treat the underlying causes and precipitated symptoms.

Due to abuse of medications for diagnosed mental health problems in combination with substance abuse, many clients believe their medication is not effective. Clients will often find (after a period of sobriety), that it is the opposite; either clients were initially misdiagnosed or their substance abuse disorder has rendered their medications ineffective. When clients enter Reflections Treatment Program with dual diagnosis concerns, the medical team first provides a medically-managed withdrawal process to safely remove the substances being abused. Clients will be evaluated extensively by a psychiatrist to see what medications in combination with clinical treatment will be most appropriate to stabilize clients and help build a foundation that will prove most beneficial for the clients individual treatment plan. As part of the dual diagnosis recovery program, each client is assigned to a Primary Therapist (doctoral level therapist) and will receive a minimum of six individual therapy sessions per week; which includes 1:1 drug and alcohol counseling. This allows the clinical team to closely monitor each client's progress on the substance abuse and mental health spectrums. Though clients afflicted with dual diagnosis can have a more challenging time in treatment, the clinical, medical, and counseling staff at Reflections are well equipped to address these significant needs.

Occasionally, if a client needs to rule-out whether or not he/she is suffering from Bipolar Disorder (for instance), Intensive Psychological Testing is available (at an additional fee) to determine a proper diagnosis, in order to receive the best possible treatment. Furthermore, if a client is struggling with significant memory problems and is experiencing slow processing, Neuropsychological Testing may be requested (at an additional fee) to determine an accurate diagnosis, in order to receive the most appropriate treatment. Often times, it is unresolved grief and loss or untreated childhood trauma that drives one's addiction or one's relapses'; and once properly treated, the client has a more significant chance of both maintaining and sustaining his or her sobriety/recovery.

Those with co-occurring disorders face complex challenges. They have increased rates of relapse, hospitalization, homelessness, and HIV and Hepatitis C infection compared to those with either mental or substance use disorders alone. The cause of co-occurring disorders is unknown, although there are several theories.

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 withdrawal 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 sustained use of alcohol 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.

Substance use disorders can be confused with other psychiatric disorders. 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 sobriety (of duration sufficient to allow for any substance-induced post-acute-withdrawal symptoms to dissipate) up to 1 year.

Only a small proportion of those with co-occurring disorders actually receive treatment for both disorders. In 2011, it was estimated that only 12.4% of American adults with co-occurring disorders were receiving both mental health and addictions treatment. Clients with co-occurring disorders face challenges accessing treatment, as they may be excluded from mental health services if they admit to a substance abuse problem, and vice versa. There are multiple approaches to treating concurrent disorders. Partial treatment involves treating only the disorder that is considered primary. Sequential treatment involves treating the primary disorder first, and then treating the secondary disorder after the primary disorder has been stabilized. Parallel treatment involves the client receiving mental health services from one provider, and addictions services from another. Integrated treatment involves a seamless blending of interventions into a single coherent treatment package developed with a consistent philosophy and approach among care providers. With this approach, both disorders are considered primary. Integrated treatment can improve accessibility, service individualization, engagement in treatment, treatment compliance, mental health symptoms, and overall outcomes. The Substance Abuse and Mental Health Services Administration in the United States describes integrated treatment as being in the best interests or clients, programs, funders, and systems. Green suggested that treatment should be integrated, and a collaborative process between the treatment team and the patient. Furthermore, recovery should to be viewed as a marathon rather than 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.[citation needed] Medications that have proven effective include opioid replacement therapies, such as lifelong 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.


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