วารสารสมาคมจิตแพทย์แห่งประเทศไทย
Journal of the Psychiatrist Association of Thailand
ISSN: 0125-6985
บรรณาธิการ มาโนช หล่อตระกูล
Editor: Manote Lotrakul, M.D.

 อัมพร เบญจพลพิทักษ์ พ.บ.

บทคัดย่อ

ผู้ป่วยโรคทางจิตเวชที่มีปัญหาการใช้สารเสพย์ติด เป็นผู้ป่วยที่ยากต่อการประเมินและวินิจฉัยตลอดการดูแลรักษา เนื่องจากอาการและอาการแสดงที่ปรากฏในผู้ป่วยมักมีความซับซ้อนและสามารถเปลี่ยนแปลงได้ตลอดเวลา นอกจากนี้การเจ็บป่วยทางจิตเวชยังอาจเป็นได้ทั้งสาเหตุและผลของการใช้สารเสพย์ติด จากความสำคัญดังกล่าว ผู้เขียนจึงได้เรียบเรียงบทความนี้ เพื่อเป็นแนวทางในการประเมินสำหรับการวินิจฉัยผู้ป่วยกลุ่มนี้ในทางคลินิก

วารสารสมาคมจิตแพทย์แห่งประเทศไทย 2541; 43(2): 167-72.

Amporn Benjaponpitak M.D. *

 Abstract

Dual diagnosis is itself a vague term. Theoretically, the term could apply to any combination of disorders taken from the Diagnostic and Statistic Manual of Mental Disorders (DSM IV)(1). However, practically, the meaning of dual diagnosis has been described into four patterns(2):

1. primary psychiatric illness with subsequent substance abuse;

2. primary substance abuse with psychopathologic sequele;

3. dual primary diagnosis, and

4. situations in which there is a common etiology (one common factor causing both problems).

In addition, it should be noticed that dual diagnosed patient is not the same as an individual who is considered ‘dual addicted’ , that is , addicted to more than one substance or behavior. It should also be noticed that many believe that all substance dependent patients suffer from a certain amount of mood dysfunction and personality deficit(3).

The prevalence of dual diagnosis conditions varies remarkably depending on the bias of the assessment team, the clinical situation in which the evaluation takes place, the category of psychiatric disorder that is used as an index, the severity of the disorders, the group of substance abusers that is selected for study and the patient’s perspective. However, it can be concluded that the prevalence of coexisting substance abuser, dependency, and psychopathology is remarkably high(4). For instance, data from the Epidemiologic Catchment Area (ECA) study, a survey of 20,000 people from five sites using the National Institute of Mental Health (NIMH) Diagnostic Interview Schedule, suggests that more than half the people who abuse drugs other than alcohol have at least one comorbid mental illness. Cocaine abusers demonstrate an additional psychiatric illness in 76% of case. The prevalence of comorbid substance abuse disorders and psychiatric illnesses was 81%(5).

Current evidence indicates that the presence of psychiatric comorbidity affects the onset, clinical course, treatment compliance, and prognosis for patients with substance use disorders. Patients with no comorbid psychiatric illness did well in all types of treatment settings, whereas patients with more severe psychiatric symptoms did poorly and associated with high rate of treatment dropout(6,7,8). In addition, patients with comorbidities benefit from specific treatment for their comorbid disorders(9). Therefore, all patients with substance use disorders should be carefully assessed the presence of psychiatric comorbidity.

 CLINICAL MANIFESTATION

There are significant problems inherent in determining a dual diagnosis in a chemical dependent person. In the stage of acute intoxication, stimulants such as cocaine can induce a paranoid state that resemble schizophrenia(10). Anxiety, irritability, increased aggressivity, impaired impulse control, and impaired reality testing may be due either to the direct effects of the substance(s) or to a withdrawal syndrome. Cocaine, hallucinogens, phencyclidine (PCP) or alcohol use can be associated with aggression. Substances that lead to withdrawal syndromes associated with a risk of violence include alcohol, opioids and hypnotic sedatives(11). Patient intoxicated on marijuana or hallucinogens may commit violent acts on the basis of their faulty perception of reality(12). In addition, addiction to many different drugs, including alcohol, opiates and stimulants can make users in a state that looks and feels like depression, featuring symptoms such as appetite and sleep disturbance, fatigue, anxiety, and irritability(13,14).

Other than major psychiatric disorders (axis I disorders), personality disorders are also frequently difficult to determine in chronic drug users. Many patients are diagnosed while under the influence of the drugs or soon after, whereas some aspects of personality disorders are primary and stem from the interaction of early developmental wounds and experiences with biological predisposition.

Some personality disorders become more severe with abstinence because of the removal of affect- or behavior-dampening drugs and alcohol, or the unavailability of substance-related behavior patterns. Some achieve healthier personality adaptations after months of abstinence. However, personality disorders that appear to be resolved can re-emerge rapidly after relapse(15).

 GENERAL CONSIDERATION

The probability that the patient has a comorbid psychiatric disorder is increased if (16);

1. there is a clear history of similar signs and symptoms preceeding the onset of substance use disorder or evident during previous extended drug-free periods; or
2. at least one-first degree biological relative has a documented history of similar illness.

 ASSESSMENT FOR DUAL DISORDERS

Assessment of the patients should contain;

1) Complete drug history The first focus is the onset of substance use. At what age was each drug initiated? A thorough review of complete drug history should also include the duration and pattern of use, the subjective and objective effects of drug, and an exploration of the meaning the chosen drug has for the patient. When was usage increased or stopped and why? The determination of premorbid psychopathology is enhanced by assessing the choice of drugs, pattern of use, and positive and negative effects the drugs have had on the patient. For example, a borderline person may take drugs in disorganized chaotic pattern, whereas an obsessive-compulsive physician may take benzodiazepine or alcohol at carefully prescribed intervals. In addition, the evaluation should include an understanding of the withdrawal symptomatology, medical sequele, and the events leading to treatment.

2) Psychiatric symptoms history The history should contain details of each prior psychiatric symptom, particularly the suicidal ideation or acts or violence, hospitalization, therapies, and medications. If these data are summarized on a time line, the temporal relationships between substance use and psychiatric symptoms will become clearer.

3) Extent of loss or social deterioration Characterization of the extent of loss or social deterioration associated with drug use is essential to understand the interpersonal, legal, education, medical, and employment consequences the patient faces.

4) The use of collateral interviews Patients are often poor historians due to denial, deliberate obfuscation, or memory problems subsequent to the drug use. Outside sources such as family, friends, employers, and probation officers should be interviewed. This technique not only results in additional history but also enable the clinicians to obtain further family history and observation on the patient’s functioning during substance-free intervals.

5) Observation of the patient Since patients often fail to serve as a reliable historians, and family members are not always available for the assessment process, history alone is not an adequate guide. Observation of the patient during intervals free of drug use can be invaluable when trying to determine the presence of a dual disorder.

There is a range of opinion as to how much sober time to allow in order to see whether the patient’s psychiatric symptoms resolve with the onset of abstinence. By conservative estimate, it could take 6 months of abstinence before the picture of a patient's baseline functioning emerges, but most clinicians use a timetable of 4-6 weeks to allow for full detoxification from drug use and for sufficient sobriety to be in place to assume that a patient’s functioning and feelings are relatively free of the influence of drug. If a patient psychiatric complaints persist beyond this point they are more likely to stem from actual psychopathology-indicative of dual diagnosis-than they are from drug toxicity and effect. Conversely, if by this point a patient’s symptoms subside, they are likely to have been by-products of drug use and not evidence of mental disorder. In the latter case, where symptoms arise secondary to drug use, dual diagnosis does not exist. However, certain psychiatric disorders, such as panic disorder and manic episode, may occur infrequently and would not be expected to appear during each or even most substance-free intervals. Chronic depression and anxiety disorders, as well as personality disorders, are likely to be detectable during periods of prolonged abstinence(16,17).

The need to allow for time and repeated observation in diagnosing newly sober patients has led experts to agree that a longitudinal approach to assessment is in order with individuals considered likely to be dually diagnosed(18).

 SUMMARY

The recent attention to the dual diagnosis patients has resulted from the recognition of both alcohol and mental health specialist groups that there was a subgroup with whom neither sector worked well and a concern that the number of individuals in this group was growing. These individuals often require treatment for the other psychopathology as well as addiction problem.

The understanding of precise diagnostic and assessment strategies can lead to a proper management for persons entering treatment who are experiencing both a substance problem and a psychiatric condition.

 REFERENCES

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