Meaning Of Dual Diagnosis

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Meaning Of Dual Diagnosis

In This Guide

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KEY TAKEAWAYS

Dual diagnosis means suffering from a substance/alcohol use disorder and a psychiatric disorder simultaneously [1].

What Is Dual Diagnosis

Dual diagnosis represents a dual pathology intersection where mental health and substance abuse diagnoses meet.

The interconnected nature and simultaneous timing of the underlying issues make it difficult to understand and treat the condition fully:

Each condition can exacerbate the other, complicating treatment
Patients are likely to be rejected by addiction and mental health programmes until one or the other condition is alleviated
Patients are likely to be misdiagnosed and not receive the correct treatment [2]
Medical professionals in different locations ascribe differing meanings to dual diagnosis, changing treatment priorities and long-term treatment outcomes [3]

Assumed Attributes Of Dual Diagnosis

Professionals working with dual diagnosis typically assume shared characteristics in dual diagnosis patients:

Difficulty identifying dual diagnosis, particularly if medical professionals are not diagnosing two separate conditions
Limited academic research resources covering dual diagnosis
Lack of standardised definition of dual diagnosis
Potential for misdiagnosis when drug/alcohol abuse is not detected in mental health treatment or vice versa [4]
Difficulties accessing insurance policies that cover dual diagnosis care: insurers may claim that dual diagnosis care was not medically needed [5]
Higher patient complexity and co-morbidity of other issues
Higher chronicity of dual diagnosis compared to other acute conditions [6]
The high degree of person-centred care necessary
The need for completely new or unique therapeutic interventions [7]
The need for different professional teams to collaborate more than normal during treatment
The long-term, dynamic, and continually changing nature of dual diagnosis symptoms
The need for ongoing re-assessment and re-evaluation of patients' needs
Possibility of combined medications during treatment causing negative reactions [8]
Possibility of medication typically used to treat one disorder exacerbating the other disorder
Previously not having received the correct support from either addiction or mental health services [9]

Meaning Of Dual Diagnosis In Professional Assessment Tools

Header	Diagnostic And Statistical Manual Of Mental Disorders (DSM-5)	Addiction Severity Index (ASI)	Clinical Institute Withdrawal Assessment (CIWA-Ar)
Definition Of Dual Diagnosis	One or more mental health and substance abuse disorders	A drug or alcohol dependency combined with a mental health disorder	Alcoholism combined with mental illness symptoms
How Definition Differs	Considers all forms of mental health and substance abuse as dual diagnosis [10]	Classes dual diagnosis and co-occurring conditions as the same [11]	Only considers the physical symptoms of diagnosis [12]

Header	Severity Of Alcohol Dependence Questionnaire (SADQ)	Assessment Of Dual Diagnosis (ADD)
Definition Of Dual Diagnosis	Alcohol dependency combined with a mental health disorder	Patient must suffer from one or more: Mania, depression, anxiety, PTSD, substance abuse, somatoform disorders, dementia, schizophrenia, personality disorders or eating disorders
How Definition Differs	Primarily focuses on emotional effects of diagnosis [13]	Highlights specific conditions that qualify as dual diagnosis [14]

Dual Diagnosis As Defined By Professionals In The Field

Psychiatrists in the field may define dual diagnosis differently from standardised DSM-5 or other definitions:

Using a 'working diagnosis' of dual diagnosis even if symptoms do not fit into established criteria to progress with treatment [15]
Comparing the severity of mental health disorder to the severity of substance abuse to organise individualised effective care when a joined-up approach is not available
Considering co-occurring learning disabilities when considering dual diagnosis [16]

Dual Diagnosis Is Not

Comorbidity/Co-Occurring Disorders Vs Dual Diagnosis

Co-Occurring/Comorbid Disorders	Dual Diagnosis
One disorder followed by another, or disorders occurring one after another sequentially	Each disorder occurs simultaneously
Neither disorder has been caused or triggered by symptoms of the other	Can be caused by symptoms of the other disorder
Sequential treatment not prioritising either disorder	Integrated and simultaneous mental health and substance abuse treatment

Substance Misuse Alone Vs Dual Diagnosis

Dual diagnosis is defined as the presence of a separate psychiatric disorder alongside substance misuse.

Whereas, substance misuse alone may cause symptoms of psychiatric complaints, but is not a standalone psychiatric disorder.

Complex Mental Health Diagnoses Vs Dual Diagnosis

Complex mental health diagnoses include:

Schizophrenia
Bipolar disorder
Post-traumatic stress disorder
Anorexia or bulimia
Personality disorders (e.g. multiple personality disorder, borderline personality disorder)

Whereas dual diagnosis is the presence of a mental health disorder and an alcohol or substance use disorder existing simultaneously.

Behavioural Health Diagnoses Vs Dual Diagnosis

A behavioural health disorder is caused by behavioural issues, such as:

Substance use disorder
Anorexia or bulimia
Gambling addiction
Sex addiction

Whereas, dual diagnoses as a mental health disorder can be caused by underlying brain chemistry, or genetic factors.

Attempts To Standardise Meaning Of Dual Diagnosis

Attempts to standardise meaning of dual diagnosis have been unsuccessful, leading to distinctions in diagnosis criteria, including:

A severe mental health disorder and substance abuse
Any form of mental health disorder and drug or alcohol dependency

This lack of universally accepted definition has led to inconsistent care, as medical professionals do not have enough research available to substantiate the effectiveness of different treatments.

Establishing diagnostic criteria for dual diagnosis allows researchers to develop appropriate treatments for different varieties of dual diagnosis [17].

How The Meaning Of Dual Diagnosis Changes According To Setting

Rehab Clinic

In a rehab setting, the meaning of dual diagnosis and co-occurring conditions are synonymous for the purpose of treatment.

Hospital

The meaning of dual diagnosis in hospitals primarily focuses on mental illness and considers alcohol secondarily.

For example, dual diagnosis treatment focuses on:

How alcohol has been used to self-medicate symptoms of mental illness
How alcohol has caused mental health disorders being treated as part of dual diagnosis [15]

Research Environment/Academic Papers

The lack of a standard academic definition of dual diagnosis has led to differing meanings of dual diagnoses, such as:

Defining dual diagnosis as primarily a severe mental illness combined with secondary substance abuse [18]
Defining dual diagnosis as primarily alcohol abuse combined with one or more secondary psychiatric complaints [19]

Insurance Policies

Insurance policies deal with dual diagnosis as separate claims for substance abuse and mental health disorders [20].

Meaning Of Dual Diagnosis In Different Locations

In Canada, dual diagnosis refers to the presence of a learning disability and a psychiatric disorder [21].

In the UK and other countries with nationalised healthcare, difficulties arise when accessing joined-up treatment for simultaneous mental health disorders and addiction due to a lack of funding and service availability.

Countries with diverse ethnic backgrounds experience:

Language barriers affecting patient's understanding of dual diagnoses
Religious or cultural stigma of addiction/mental health disorders affects treatment accessibility
Different cultures are offended by personal questions and do not continue treatment [22]

Header	Patient Diagnosed With Dual Diagnosis in USA	Patient Diagnosed With Dual Diagnosis in UK
Definition Of Dual Diagnosis	Any form of mental illness and combined alcohol or drug dependency	Severe mental illness and combined drug dependency
Service Availability	Private treatment - joined-up care at a cost	NHS treatment - going to different specialists causes lack of continuity of care
Cultural Attitudes Towards Mental Illness	Stigma endorses secret drinking and not getting treatment [23]	Public mental health campaigns reduce stigma and increase accessibility of treatment [24]
Long-Term Treatment Outcomes	12% receive integrated dual-diagnosis treatment [25]	50% receive integrated dual diagnosis treatment [26]

Legislation & Regulation May Change How Dual Diagnosis Is Defined

Differing regulations or oversight in policies can influence how dual diagnosis is defined due to:

Medical professionals using the ICPC-2 finding that having three appointments and physical testing causes oversight of dual diagnosis symptoms [27]
Alcohol or mental illness scales used in regulations not correctly diagnosing dual diagnosis
The Global Disease Burden considers neurological disorders (e.g. Parkinson's and epilepsy) as part of dual diagnosis [28]
The North American Nursing Diagnosis Association (NANDA) uses a nursing diagnosis that focuses on the physical response to illness that informs intervention, this may cause polydrug use to be considered the cause of symptoms and not dual diagnosis [29]

How The Meaning Of Dual Diagnosis Changes Treatment Priorities

The meaning given to dual diagnosis changes:

What is considered a dual diagnosis - is Parkinson's or epilepsy included? Are all mental health disorders included or just those considered severe?
How treatment is prioritised - whether mental health disorder or addiction is treated first
What aspects of treatment are available - e.g. secondary diagnosis of mental health disorders due to nursing diagnosis leads to longer waiting lists for treatment
Access to differing medication types or regimens - these may not be in line with specific medical professional's definition of dual diagnosis and therefore not prescribed

Order And Sequence Of Dual Diagnosis Treatment May Change

The order and sequence of dual diagnoses may change due to:

Initially using nursing diagnosis may cause the medical professionals to miss underlying causes or the possibility of multiple diagnoses causing symptoms that are only noticed sequentially
Initially using the ICPC-2 to focus on physical tests for symptoms may miss psychological symptoms that alter diagnosis

Dual Diagnosis Meaning Can Impact Patient Care Plans

Elements Of A Care Plan	Dual Diagnosis Meaning A Severe Mental Health Disorder And Substance Abuse	Dual Diagnosis Meaning Any Mental Health Disorder And Alcohol Or Drug Dependency
Current lifestyle and history of abuse	May overlook less advanced mental health issues that affect substance abuse	Focuses on co-occurring symptoms of mental illness and addiction
Psychiatric care needs	May not consider link between less advanced mental health disorders (e.g. anxiety and depression) and substance abuse when planning psychiatric care needs	Will consider the link between all mental health disorders and alcohol and drug dependency to inform psychiatric care needs
Motivations/ actions taken to get into recovery	Not classing patients as dual diagnosis could mean not believing they are sufficiently motivated to attend rehab	Will be aware that complex cases of dual diagnosis cause patients to struggle to be motivated to seek help
Risk assessment	Misdiagnosis of dual diagnosis could cause risks to be unaccounted for	Considers risks to self and others when starting treatment

Impact Of Differing Dual Diagnoses Definitions, On Patients' Lives

Header	Dual Diagnosis Diagnosed Via DSM-5	Dual Diagnosis Diagnosed Via ICD
Differing definition of dual diagnosis	Focused on classifying mental health disorders, leading to a quick diagnosis	Classifies all forms of disorders, leading to a longer diagnosis/diagnosis of physical symptoms and not mental health
Family and social support	Correct social support can be in place when needed	Social support may not be relevant when needed due to longer diagnosis
Experience of stigma	Some feel stigmatised due to labelling mental health disorders	Using codes for symptoms and diagnoses to avoid stigma
Treatment by other medical professionals	Classification may not be understood by other medical professionals, disrupting treatment	Classification is understood by other medical professionals
Access to care and support	Immediate access to joined-up care	Can be delayed access due to more extended diagnosis
Self esteem and psychological impact of diagnosis affecting relationships with others	Labelling mental health disorders leads to lower self esteem and negative relationships with others	Inclusive view of health improves self esteem and encourages better relationships with family
Aftercare	Individualised aftercare plan using DSM-5 to track progress and adjust plan if needed	Aftercare plan is not as detailed and uses holistic approach

About the author

Harriet Garfoot

Harriet Garfoot BA, MA has an Undergraduate degree in Education Studies and English, and a Master's degree in English Literature, from Bishop Grosseteste University. Harriet writes on stress & mental health, and is a member of the Burney Society. Content reviewed by Laura Morris (Clinical Lead).

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Last Updated: March 27, 2024