The dual pathology is the concurrence in the same individual of, on the one hand, a disorder due to substance use and, on the other, a comorbid psychiatric disorder.
The prevalence of this comorbidity situation is high, so that the term of dual pathology is usually reserved for those cases of drug abuse and dependence together with the comorbid presence of serious mental disorders, especially psychotic and / or affective.
Characteristics of dual pathology
In dual pathology addiction can be a substance or behavior ( pathological gambling ). Regarding substances, they can be accepted culturally as xanthines (coffee, theine), alcohol or tobacco or those not accepted as cannabis, opiates or stimulants.
On the other hand, mental disorders are usually mood disorders (for example, Major Depression or Bipolar Disorder ), anxiety disorders (for example , Generalized Anxiety Disorder or Social Anxiety Disorder ), Personality Disorders, Psychotic Disorders or Disorder deficit Attention Disorder (ADHD).
The importance of this comorbidity has been evidenced in numerous studies due to the influence it has for the clinical treatment, for the evolution of both disorders and for the costs that it generates.
The use of psychoactive substances is strongly associated with psychiatric morbidity, not only in adults but also in the early stages of life.
In our society, substance abuse is a problem that concerns public health. Within the general population, the percentage of people who consume or have consumed some type of legal / illegal substance at some point in their life is very high.
Epidemiology of the dual patient
Dual pathology is a serious problem given its epidemiological rates. The different studies in the general population and in the clinical population have shown that the comorbidity between a mental disorder and a substance use disorder is between 15 and 80%.
It is also pointed out that around 50% of people with mental disorders meet criteria for substance use disorder at some point throughout their life cycle.
About 55% of adults who have a substance use disorder also had a diagnosis of psychiatric disorder before age 15.
In addition, different studies have shown that prevalences of comorbidity in psychiatric patients with substance use disorders are higher than those in the general population, which are between 15 and 20%.
For example, a study by Crowley et al. (1979) noted that about one third of patients who were admitted to a psychiatric hospital had a substance use disorder at the same time.
A large number of epidemiological and clinical studies conducted since the 1980s showed that the incidence of psychiatric disorders is higher in subjects with substance use disorders.
Likewise, also patients with psychiatric disorders have a greater propensity or vulnerability to consume psychoactive substances.
Dual patients are serious from a clinical and social point of view.
From the health system it is necessary to face the double need that they present: on the one hand, to attend from mental health to their psychiatric disorder; on the other, from drug addictions, to attend to their addiction.
Dual patient profile
Patients with dual pathology, compared to those who only have a diagnosis of substance use or only mental disorder, usually require more hospitalization and more frequent emergency care.
In addition, they suppose an increase in the sanitary cost, greater medical comorbidity, higher rates of suicide, worse adherence to the treatment and their results of treatment are scarce.
They also present higher unemployment, marginalization, disruptive behavior and risk. In addition, higher risk of infections such as human immunodeficiency virus ( HIV ), hepatits, etc., and more self and heteroagresivas behaviors.
Very often they lack social support networks, live in circumstances that we can consider stressful, suffer from several drug dependencies (pattern of polydrug use) and have a high risk of becoming homeless.
They usually present a lack of awareness of illness, difficulty in assuming and communicating that they present an addiction. In addition, they are usually identified with only one of the disorders, drug dependence or psychiatric disorder.
They have a high failure rate in previous therapeutic interventions and a high probability of having relapses.
In relation to substances, excluding nicotine, the drug most commonly used in dual pathology is usually alcohol, then cannabis and followed by cocaine / stimulants.
The natural evolution of severe dual pathology tends to worsen social adaptation, aggravate their maladaptive behaviors and often end up in problems such as prison income, psychiatric hospitalization and social exclusion.
In addition, sometimes, identifying clearly and validly the dual diagnosis can be complicated. This is because the drugs act on the Central Nervous System and its effects may resemble the symptoms of some mental disorders.
For example, the insomnia generated by a drug can be confused with that which is specific to a Major Depression disorder, so that differentiating psychopathological symptoms from the effects of drugs independently can be complicated.
In addition, we must bear in mind that mental disorders are syndromes insofar as they present a set of joint symptoms and do not present clear biological markers that allow us to identify and validate a diagnosis.
Other sociodemographic characteristics of the dual pathology profile, according to studies, are that it has been observed that there is a higher proportion of males, a greater number of single individuals or a greater number of crimes with legal repercussions.
Other studies have also found a higher prevalence of low socioeconomic status or lower level of education.
Likewise, it has also been observed that there are higher levels of consumption among those with a family history of consumption.
As already mentioned, the first drug consumed is nicotine, which is considered the first cause of morbidity and mortality in the western world and has repercussions in a large number of pathologies (cardiovascular, respiratory …).
After this, alcohol, cannabis and cocaine are the most consumed drugs. In dual pathology, polydrug use is the most prevalent form of consumption.
Also the type of drug consumed varies according to the psychiatric disorder to which we refer.
For example, some studies have found that within schizophrenia, the most commonly consumed drugs are alcohol and cannabis, while cocaine is consumed by a smaller percentage of patients with schizophrenia.
However, in schizophreniform psychoses, for example, the pattern changes and the drugs most consumed are cannabis and cocaine, with alcohol being consumed less by individuals with said psychiatric pathology.
There is no need to attend to drugs considered “more problematic”. The xanthines (caffeine, theine …), perhaps those considered more “normal” for the population, can also enhance the consumption of other substances.
About 66% of patients who consume a lot of caffeine, also consume sedatives and hypnotics. When doses are low, xanthines produce euphoria and are reinforcing, but at higher doses can produce dysphoria and anxiety.
Causes of dual pathology
Most students of dual pathology (such as Casas, 2008) indicate that dual pathology is the result of different etiological variables .
These are both genetic and environmental and also feed each other, generating neurobiological changes in which they create cognitions, emotions and behaviors that lead to mental illness formed by two entities: a mental disorder and an addiction.
We found several hypotheses that explain the comorbidity between a substance use disorder and a mental disorder.
On the one hand, one of the hypotheses indicates that addiction as well as other psychiatric disorders are symptomatic expressions other than similar neurobiological anomalies .
There may be a special vulnerability on the part of the subject to suffer both disorders. For example, it would be the example of personality disorders .
On the other hand, another hypothesis indicates that by administering drugs in a continuous and recurrent manner, through neurological adaptation mechanisms, neurobiological changes arise that present common elements with the anomalies present in various disorders.
In this way, we understand that the relationship between substance use disorders and mental disorders varies according to each of the disorders.
Therefore, in dual pathology there may be several possibilities. On the one hand, the first disorder can influence when developing the second, so that the latter, thereafter, follows its course independent of the first.
In this case, we could see how from the consumption of certain substances, a psychosis can develop, for example. This is exemplified in the consumption of cannabis that gives rise to a psychotic outbreak.
In this way, a drug dependence occurs as a primary disorder that induces psychiatric pathology. It is the mechanism that defends the theory of neurotoxicity.
The most frequent symptoms resulting from drug use are depression, anxiety and psychotic outbreaks from drugs such as cannabis, alcohol, cocaine and other stimulants.
However, the opposite example can also be given, that is to say, that from a mental or psychiatric disorder a disorder due to substance use develops .
For example, during a manic episode where the person consumes alcohol can lead to an alcohol use disorder.
In this case, psychopathology is the risk factor for developing a dependence on drugs. Consumption occurs to relieve various symptoms such as depression or anxiety.
We must bear in mind that another possibility in this relationship is the fact that the consumption of substances can attenuate the psychiatric symptoms of a disorder that either is not adequately treated or may have gone unnoticed and not been diagnosed.
In this case, if we treat the psychiatric disorder, the consumption of substances can disappear.
It is also possible that the relationship between the two is independent. That is, the same person presents a psychiatric disorder and independently a substance use disorder. In this case, the intervention must be independent.
Finally, we must distinguish in the relationship between the two, that some syndromes can be temporary psychiatric symptoms and that once the time has passed, it stabilizes. This is the case of a psychosis semblante to schizophrenia that is due to intoxication due to drug use.
We must bear in mind that some hypothesis also suggests that the early onset of substance use is associated with a greater probability of presenting a dual pathology in adolescence.
Different authors warn that there may be a common vulnerability factor common to childhood, adolescence and adulthood.
In this sense, the vulnerability that leads the child to present a behavioral problem, may lead him in adolescence to present a pathology due to substance use, both problems being different manifestations of the same problem.
Following the etiology and predisposing factors to dual pathology, we can highlight its multifactorial character.
On the one hand, we describe the genetic factor (temperamental) and, on the other, the environmental factor (above all, the influence of the family, which we have previously argued is that there is more tendency towards consumption with a familiar pattern of consumption).
The different studies collect three areas of study in terms of predisposition to dual pathology: the relationship between behavior and genes, emotional expressivity and the interaction between family dynamics and childhood pathology.
When a family is balanced, it presents cohesion and warmth among the different members; they are able to adapt optimally to the changes that happen throughout life.
However, families with problems are against it. When there are more family conflicts, this is related to the onset and greater consumption of substances as well as behavioral problems in its members.
There is also influence of the group of equals, important at these ages, modulated by the general dynamics and leading in many cases to the adolescent to school failure, antisocial behaviors or marginalization.
Regarding the etiology of psychiatric disorders, the psychiatric antecedents of the parents are crucial.
It is due not only to the genetic etiology but also to the influence of the environment, due to patterns of discipline and parental modeling.
For example, interactions can be based on physical punishment, violence, etc., which facilitate the early onset of abuse and other antisocial behaviors in children .
Diagnosis and treatment guidelines
As we have already mentioned, there is great variability in dual pathology. All this makes it difficult to make a correct diagnosis of what psychopathology patients with substance use present.
There are different factors that at the same time make this diagnosis difficult, such as the denial of drug use by the subject or his family members, distorted information, problems of the psychotherapist, modification of psychiatric symptoms due to consumption, and so on.
The most accurate and appropriate treatment that these patients should follow, both pharmacologically and psychosocially, still lacks.
Occasionally, applied pharmacology for treatment has been studied in patients with psychiatric disorders but without substance use, or in patients with consumption disorder but without comorbid psychiatric disorder.
This presents a problem when we try to apply it to people with dual pathology, since the interactions, tolerance, side effects, etc., may be different.
The same happens in psychological therapy, given that strategies or therapies that have been effective to treat addictive behavior may lack efficacy or be harmful when we also deal with patients who also have psychiatric pathology.
It should be noted that both group therapy, contingency therapy and residential treatments have been shown as useful treatments for people with dual pathology.
Likewise, studies indicate that patients with dual pathology should receive comprehensive care, so that addiction and psychiatric pathology are addressed simultaneously , thus guaranteeing long-term results.
In rehabilitation, dual pathology involves difficulties and also risks. They tend to maintain better interpersonal skills, but when they use drugs they have less prospects of recovering.
Adherence to treatment and staying in a rehabilitation program is expensive, so that the professionals and devices they go to must be flexible.
The strategies that are recommended to treat patients with dual pathology are their participation, motivation, work with the environment, use psychoeducational approaches , individualize the treatment, give them tools to train them and work in a coordinated way all professionals.
The rehabilitation consists of helping the subject with tools to plan his life, help him to recover skills and confidence in himself. You have to help him recover his autonomy.
Including the family in the treatment of the patient with dual pathology favors adherence to the treatment and fulfills it better, opens the possibility to reduce the reactive conflict to consumption and therefore also reduces the anxiety that causes keep abstinence better.
The treatments that can be given for the dual pathology are the parallel treatment, where at the same time it intervenes in both problems.
It can be a sequential treatment, where treatment is received for one of the problems, usually the most serious, to continue with the next one once the first one is stable.
Finally, an integrated treatment, where both are treated but within an integral program, jointly and by the same work team.
This last treatment is the most necessary to work both drug addiction and psychiatric psychopathology. It is encompassed within a biopsychosocial perspective and with a multidisciplinary team.
Taking into account the basic principles of treatment, according to what is proposed by the NIDA (National Institute on Drog Abuse) of the United States, which regulates effective treatments, the importance of individualized treatment and the integration of pharmacological treatment and treatment is emphasized. psychosocial
Psychosocial treatment is the one that improves the prognosis of patients because there is better adherence to treatment, longer time of abstinence and less total consumption.
Keep in mind that the effectiveness and treatment depends on the severity of the psychiatric disorder, the severity of the substance use disorder and the interaction between them.
In the psychological treatment or intervention, the first part consists in stabilizing the patient, attending to the psychiatric symptoms that it presents, to those that are derived from the addictive behavior and to complete the evaluation.
The dual patient requires more attention and time, greater skills on the part of the professional at the time of serving and greater acceptance and tolerance.
You must establish goals that the patient can achieve, reduce consumption and increase adherence to treatment.
We must get the patient aware of their problem, work on the desire to consume and relapse prevention, their social support and social skills and coping strategies.
It is essential to work on improving family dynamics and rehabilitation at different levels, be it family, social, work …
The intervention must be motivational, psychoeducation, socio-family and through techniques such as relapse prevention, contingency management, problem solving techniques and relapse prevention.
The aim is for the patient to know his or her illness, to comply with the treatment, to prevent the consumption of toxins and psychiatric symptoms, to learn to manage their symptoms and to solve and deal with problems.
It is intended to increase welfare, communication with others and know how to deal with different social situations.
2. Cognitive-behavioral approach
This approach argues that the symptom is an expression of maladaptive thoughts and beliefs that are due to the personal history of learning.
To deal with additive behaviors, multicomponent programs are used.
3. Motivational intervention
It is crucial because adherence to treatment depends on it. It is about taking into account the patient, their opinions, needs, motivations, solutions, their characteristics …
It is about the patient participating in the treatment and promoting the change from himself.
4. Social and family intervention
Dual pathology has a negative effect on the families of patients. The family feels fear, anger, guilt , etc.
It is also about working with the families to work on the maintenance of the treatment, to work on inappropriate behaviors, etc., also offering them emotional support.
Future challenges in dual pathology
Studying dual pathology in the future presents great challenges. It is a serious problem given the comorbidity of several disorders that require attention, given the high prevalence rates, the relationship between both disorders and the therapeutic difficulty that presents.
It is necessary to know the neurobiological bases, characterize it in a clinical and diagnostic way and develop appropriate treatments from the pharmacological, psychological and social point of view . As well as the place where the treatment will be carried out (mental health centers, addiction centers).
If we can better understand the relationships between the different variables that influence the development of pathologies, we can deepen the study and design strategies to assess, prevent and work on the most relevant factors and reduce the incidence and morbidity of the pathology. dual, substance use disorder and psychiatric disorders.