Dual diagnosis means that an individual has two separate but very interrelated diagnoses:

1. A psychiatric problem
2. An addiction problem

It is difficult to say which came first. What is important to note is that the person is currently having both problems and both have to be addressed together. A relapse in one of the two areas can trigger a relapse in the other.

Dual Diagnosis profiles may include the following:

1. Severe/major mental illness and a substance disorder(s)
2. Substance disorder(s) and a personality disorder(s)
3. Substance disorder(s), personality disorder(s) and substance induced acute symptoms that may require psychiatric care, i.e., hallucinations, depression, and other symptoms resulting from substance abuse or withdrawal.

How Common Is Dual Diagnosis?

Dual diagnosis is more common than you might imagine. According to a report published by the Journal of the American Medical Association*:

Thirty-seven percent of alcohol abusers and fifty-three percent of drug abusers also have at least one serious mental illness.

Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.

What Kind of Mental or Emotional Problems are Seen in People with Dual Diagnosis?

The following psychiatric problems are common to occur in dual diagnosis - i.e., in tandem with alcohol or drug dependency:

• Depressive disorders, such as depression and bipolar disorder
• Anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias
• Other psychiatric disorders, such as schizophrenia and personality disorders.

Depression

Depression is a serious medical illness that involves the brain. Symptoms can include:

• Sadness
• Loss of interest or pleasure in activities you used to enjoy
• Change in weight
• Difficulty sleeping or oversleeping
• Energy loss
• Feelings of worthlessness
• Thoughts of death or suicide

Depression can run in families, and usually starts between the ages of 15 and 30. It is much more common in women. Women can also get postpartum depression after the birth of a baby. Some people get seasonal affective disorder in the winter. Depression is one part of bipolar disorder.

There are effective treatments for depression, including antidepressants and talk therapy. Most people do best by using both.

Bipolar Disorder

Also called: Manic-depressive illness

Bipolar disorder is a serious mental illness. People who have it experience dramatic mood swings. They may go from overly energetic, "high" and/or irritable, to sad and hopeless, and then back again. They often have normal moods in between. The up feeling is called mania. The down feeling is depression.

Bipolar disorder can run in families. It usually starts in late adolescence or early adulthood. If you think you may have it, tell your health care provider. A medical checkup can rule out other illnesses that might cause your mood changes.

Untreated, bipolar disorder can result in damaged relationships, poor job or school performance, and even suicide. However, there are effective treatments: medicines and "talk therapy". A combination usually works best.

Anxiety

Fear and anxiety are part of life. You may feel anxious before you take a test or walk down a dark street. This kind of anxiety is useful - it can make you more alert or careful. It usually ends soon after you are out of the situation that caused it. But for millions of people in the United States, the anxiety does not go away, and gets worse over time. They may have chest pains or nightmares. They may even be afraid to leave home. These people have anxiety disorders. Types include

• Panic disorder
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Phobias
• Generalized anxiety disorder

Treatment can involve medicines, therapy or both

Schizophrenia

Schizophrenia is a severe, lifelong brain disorder. People who have it may hear voices, see things that aren't there or believe that others are reading or controlling their minds. In men, symptoms usually start in the late teens and early 20s. They include hallucinations, or seeing things, and delusions such as hearing voices. For women, they start in the mid-20s to early 30s. Other symptoms include

• Unusual thoughts or perceptions
• Disorders of movement
• Difficulty speaking and expressing emotion
• Problems with attention, memory and organization

No one is sure what causes schizophrenia, but your genetic makeup and brain chemistry probably play a role. Medicines can relieve many of the symptoms, but it can take several tries before you find the right drug. You can reduce relapses by staying on your medicine for as long as your doctor recommends. With treatment, many people improve enough to lead satisfying lives.

Personality Disorders

Personality disorders are long-term patterns of thoughts and behaviors that cause serious problems with relationships and work. People with personality disorders have difficulty dealing with everyday stresses and problems. They often have stormy relationships with other people. The exact cause of personality disorders is unknown. However, genes and childhood experiences may play a role.

Symptoms vary widely depending on the specific type of personality disorder. Treatment usually includes talk therapy and sometimes medicine.

Which Develops First - Substance Abuse or the Emotional Problem?

It depends. Often the psychiatric problem develops first. In an attempt to feel calmer, peppier, or more cheerful, a person with emotional symptoms may drink or use drugs; doctors call this "self-medication." Frequent self-medication may eventually lead to physical or psychological dependency on alcohol or drugs. If it does, the person then suffers from not just one problem, but two. In adolescents, however, drug or alcohol abuse may merge and continue into adulthood, which may contribute to the development of emotional difficulties or psychiatric disorders.

In other cases, alcohol or drug dependency is the primary condition. A person whose substance abuse problem has become severe may develop symptoms of a psychiatric disorder: perhaps episodes of depression, fits of rage, hallucinations, or suicide attempts.

How Can a Physician Tell Whether the Person's Primary Problem is Substance Abuse or an Emotional Disorder?

At the initial examination, it may be difficult to tell. Since many symptoms of severe substance abuse mimic other psychiatric conditions, the person must go through a withdrawal from alcohol and/or drugs before the physician can accurately assess whether there's an underlying psychiatric problem also.

If a Person Does Have Both an Alcohol/Drug Problem and an Emotional Problem, Which Should Be Treated First?

Ideally, both problems should be treated simultaneously. When neither illness is treated, one illness can make the other worse. When only one illness is treated, treatment is less likely to be effective. When both illnesses are treated, the chances for a full and lasting recovery are greatly improved, and it is easier to return to a full and productive life.

However, in a controlled therapeutic environment, such as a facility like HOPE, the client is first assessed by a psychiatrist and physician. His psychiatric condition has to be relatively stabilized (with medication within a protocol-oriented setting), so that he is open to other inputs such as psycho-therapy and counseling.