Diagnosis And Dual Diagnosis

People send me questions and as I have resources, I try to answer them. I've taken a few recently that have to do with helping the askers to better understand how a psychiatric diagnosis is made. I thought the topic important enough to develop into a short essay for this column.

In the simplest sense, a diagnosis is nothing more and nothing less than someone figuring out what is wrong with you. For some reason, there are only diagnoses for illnesses, never for wellnesses. When you go to the doctor and she examines you and tells you that you are depressed and dispenses some Prozac, you have been diagnosed. If she tells you that you are fine and that there is nothing wrong, you have not been diagnosed.

Mental health doctors don't make up diagnoses. Rather, we get them from a book known as the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Press. This book, known as the DSM-IV-TR (for the forth edition, text revision) is basically a long list of recognized disorders, with chapters on depression, schizophrenia-like problems, drug abuse and dependence, childhood disorders, etc. The DSM-IV-TR is the latest in a long line of previous books that sought to come up with a standardized language for talking about how people can be messed up in the head. While early versions of the DSM were heavily dependent on psychoanalytical theory, these days the disorders it contains have been pretty well scientifically studied. The book gives details on how common each disorder is, at what age it tends to get started, how it tends to affect the people who have it, and most importantly, a list of symptoms and signs that are associated with the disorder. For each disorder, there are important symptoms and signs that must be met before the diagnosis is appropriate to be made. If all the important signs and symptoms are present, the diagnosis can be made. If they are not present, no diagnosis can be made. This tight linkage between symptoms and particular disorder was intentionally created so that one doctor could diagnosis and then a different one treat, but both doctors would understand what was wrong with the patient in the same terms.

The intention of the diagnostic process is to accurately describe what is wrong with someone. If it is possible, the intention is also to link up what is wrong with someone to a known illness causing agent or process. You want to reduce the problem to known illness causing agents, because in order to treat someone, you have to understand what is going wrong. If you can put a good diagnostic lable on someone that accurately describes what is wrong with them, then you have some idea (hopefully) of what has malfunctioned to cause them to be the way they are. If you have an idea what is wrong, then you have a better chance of fixing things (prescribing the proper medicines, therapies, etc. that will "fix" the illness.).

One of the cool things about the approach of the DSM (as a method of standardizing diagnosis) is that it was designed from the ground up to recognize that mental disorders are not just mental disorders. Rather than reducing the description of a particular disorder to mere biological phenomena, the DSM requires doctors to consider the mental (psychological), biological (medical) and social aspects of mental illness. This "BioPsychoSocial" approach is achieved by dividing the diagnosis into five different sections, or "axes". Each axis has it's own roman numeral. I'll describe each of the axes in turn.

Axis I is where a doctor would write down diagnoses such as depression, anxiety, schizophrenia, drug addiction, etc. The diagnoses contained herein are all assumed to be ones that come on if not in (early or later) adulthood, than at least those that develop in someone who was healthy at one time.

Axis II is where a doctor would write down additional diagnoses related to chronic and/or developmental disorders (e.g., types of problems that originated very early in life; there was never a time where the person was "healthy" as defined by the absence of the diagnosed disorder).

Axis III is where information on a person's physical condition is recorded. Information on any significant medical disorders that could be contributing to the diagnosed individuals' stress or symptoms is noted here.

Axis IV is where doctors describe the person's social and economic situation (e.g., their living and working situations, important relationships or the lack thereof, finances, etc.).

Axis V, (the last axis) is a place to record a single number. The number in question (called the Global Assessment of Functioning) is the doctor's best educated guess for how well the person being diagnosed is functioning in the world. The GAF can range between 0 and 100 and provides a way to summarize in a single number just how seriously a person's illnesses are impacting his or her life.

A complete diagnosis might look something like this:

I: Depression, Alcholism
II: Dependent Personality Disorder
III: Diabetes
IV: Unemployment, Social Isolation
V: 55

Dual Diagnosis

You may have noticed that I've put more than one diagnosis on each of the axes in my example above. This is because, each of the axes can, in fact, have more than one diagnosis on it. This is so that the person being diagnosed can be described as completely as possible. When the first axis (Axis I) has more than one diagnosis on it, a special term is sometimes used to describe the situation. That term is "Dual Diagnosis".

Taken literally, the term Dual Diagnosis is given to a person when they carry more than one significant mental disorder diagnosis at a time. In practical use, it is used to describe those who have been blessed with both a significant mental disorder and a substance abuse diagnosis at the same time. Who are we really talking about here? Well - the population of persons who are depressed, anxious, schizophrenic, bipolar, OCD, etc. who are actively abusing or dependent on alcohol, marijuana, cocaine, heroin or similar opioids, other drugs of abuse, or even illicitly obtained (or sloppily prescribed) 'legitimate' drugs such as Valium and Xanax. There are a lot of these people out there, only many of them are not aware of this fact or don't want to be aware of this fact.

People who are dually diagnosed have a more difficult road to hoe than their single diagnosis brethren. Here are several reasons why.

1. Addictions don't get identified or treated, and the person doesn't get better.

Medicine has been making steady progress in identifing medical chemical treatments for depression and anxiety. One side effect of this progress is that it's become less stigmatizing to admit that you have a problem with depression - it's no longer a moral weakness. But, I think, addiction remains thought of primarily as a moral weakness (even though it is just as biological a problem as anything else). If Depression is now okay to have because it is due to a chemical imbalance, addiction is still viewed as the addicts fault. So people are not jumping out of the woodwork to admit they have addictions. And many physicians and other clinicians are not fully savy about dual disorder problems and so focus on the treatment of what seems to be primary (the mental illness/depression/anxiety part), while relatively ignoring the addictions part.

Ignoring the addictions part when it exists, however, is a really big mistake for several reasons. The presence of drugs in a persons system can sometimes interfere with the action of corrective medicines such as anti-depressants, rendering these needed medicines less- or not at all effective. Even worse, persons who are addicted to drugs often have trouble staying organized as their lives become increasingly oriented around obtaining more drugs. This disorganization makes it hard for them to stay on a regular pattern of daily medication. In some cases drugs of abuse contribute to - even help cause mental illnesses. Depression, for example, can be induced by drinking alcohol which is a depressant drug.

Persons whose addictions serve self-medicating purposes can be reluctant to talk to their doctors about their addictions for fear that the doctor will tell them to stop drinking or drugging. For instance, the anxious alcoholic might be reluctant to disclose the full extent of drinking taking place. Addicts comming off of alcohol and other anti-anxiety drugs experience severe anxiety as a function of physical withdrawal from the alcohol - they don't want to feel this way and so are further motivated to hide their drinking from their physician.

2. What works to treat either a mental illness alone, or a drug addiction alone, doesn't work quite as well for treating Dual Diagnoses at the same time. (Dual Disorders need special care)

Those dually diagnosed persons who do get into treatment for their drug addictions often find that the support they need is not quite all there for them. For instance, the AA organization and other similar 12-step programs are designed primarily to treat persons with addictions. The members of AA (bless them all) are zelous in their pursuit of sobriety, and don't always know when a drug is part of an addiction and when it is part of a legitimate medication regime. It is not uncommon for a new dually diagnosed participant in AA to be told that they must cease taking ALL drugs if they want to become sober (including prescribed medicines needed to treat mental illness conditions). This of course is confusing to the dual diagnosed patient who is told to be on the medicines by his/her doctors and to be off them by his/her sponsors. This sort of stress is not helpful.

To AA's credit, there are more and more "dual diagnosis" meetings for people to attend. There are also (at least in larger communities) often one or more treatment facilities that are sensitive to the special treatment needs of the dually diagnosed patient. Look for such a resource in your community if you need one (or find a social worker type person, perhaps through your local community mental health center - he or she will be able to point you in the right direction.

There is, of course, a whole lot more that can be said regarding these issues. But I thought that this would be useful information to get out there to folks who can benefit from it. Thanks for asking.

Dombeck, M.J. (Nov 2000). Diagnosis and Dual Diagnosis [Online].

  • Bonnie

    Thank you for a complete definition of assessment. My husband has SEVERE PTSD, Vietnam related, and he dropped his basket in 2002 - he could no longer "keep it" together. His psychiatrist at the VA keeps misdiagnosing him because he is very intelligent and still at times has a keen memory, therefore, when questioned he feels the need to answer the challenge - for instance, the Iraq war. In other words, his ego takes over. However, they only see him for 15-30 minutes. How can I help him to understand they are misdiagnosing him because . . . who knows why? He is now getting 100% temporary, but he would like it to be permanent. I'm afraid the stress of this fight, the loss of our business, his plane, etc. is going to finally push him over. He has been suicidal for 2 years, and at times homicidal. Can you help me to explain this to him or possibly lead me to an article for him to read that will help him to understand. Thanks

  • Sarah F.

    I am a dual diagnosis person. I got sober in AA in 1995 and thought I had found the answer--I was well for about a year and a half before I crashed and burned again, this time diagnosed with OCD. I got treatment for it and did fairly well, but chose to drink rather than kill myself in 2002 after 8 months of severe illness, then did 2 1/2 weeks of day treatment to get my mania under control. Now I am on disabiltiy after trying to work and be normal for 20 years, and I am as sick as I have ever been, finally consenting to ECT. My problem is that AA is my ENTIRE social support. When I share the proposed treatment option facing me (ongoing, regular ECT to get me better and prevent relapse) I am told "work with a drunk." I have alientated several key social contacts, and can't even find a sponsor. When I shared that I had drunk several times in my despair, one woman told me I would not have become so depressed had I kept atttending meetings--and i had jsut told her I NEVER stopped attending meetings. I am so frustrated. Were I not so completely disabled I would attempt to start a dual diagnosis meeting. One bipolar friend even stopped contacting me after hinting I was causing my own depression wiht a negative attitude. She has to work nights to get by as it is...days are too stressful. I jsut don't know where to turn--so hey, why not some stanger on the internet???

    Editor's Note: Some communities have AA groups that are set up with an appreciation of the special needs dual diagnosis patients have. To locate one near you (I hope there is one near you!), you might try calling the psychiatric hospitals and inpatient psychiatric units in your area and ask staff there where they refer dually diagnosed patients upon discharge. Good luck.

  • Kate

    My fiance has paranoid delusions that he refuses too see. he thinks his ex-wife and his family are doing everything they can to get them back together, even though they have been divorced 10 years. he thinks that I am in on it too, that his family is trying to get me to ask him questions about his ex-wife and if he would go back to her, and thinks his office, phone and computer are bugged.He believes that his family and ex-wife send in patients to ask him questions about them gettng back together, and he claims he hates her. If I suggest help, he says I am insulting his intelligence, because he is a doctor. I deeply love him, and will stand by him shall he get some sort of treatment, I just don't know exactly what he has, or how to go about getting it done. Any comments or diagnosis would be appreciated!

  • Anonymous-1

    While I certianly can't blame AA for a recent relapse, I do recall the last moments of a trying to stave off a would be sponser and depressing meetings of people commenting that only '1 in 7 make it,' and 'better him than me.' The sponser, a very controlling man treating me like a 17 year old, was demanding that I get off klonopin immediately, or find a doctor that would. I take klonpin for anxiety, and because of a my bipolar condition cannot take other drugs such as the SSRI class. I know my drugs and condition well- of the benzodiazipame family, colanzapame (klonopin) is one of the safest ones (it is an anti-convulsive rather than a sedative) and is sometimes indicated for long term usage. At first it made me a little drowsy, but I know longer feel any side effects from it. As I know I can go into potentially dangerous psychotic states from high anxiety and panic attacks, I would say klonopin has served me well, just as lithium has. Even many psychiatrists don't understand this, and are quick to label benzo subscribing doctors as irresponsible. I would suggest thay do a little more homework before making such blanket accusations.

    Deeply upset, I went home and took a slug of burbon after two months of being sober. I then laid awake in bed until 4:00 a.m., full of anxiety and misery. Although I'm certain I won't be going back to that group anymore, I am uncertian of the future. I like to work closely with flexible people and will be cautious in the future of doom and gloom AA groups and dogmatic, perhaps well-meaning but unknowledgable self-appointed sponsers. I have drank too much in the past, to the point of out and out alcoholism, and do not want to return there. I find many AA's tennants very powerful, and want to stay involved. I also believe that, no, we can't do this alone. But you must pick your group wisely.


  • Norman Gersabeck MD

    I am responsible for the state of California (quietly) using information on the diagnosis of "Substance Dependency-Induced Psychosis in their mental health system planning.

  • David

    How can you give credit to AA?AA as you say encourages people to stop taking prescibed medication...I have known people just to stop taking medication and attempt suicide.AA is a bunch of voodoo witch doctors who have zero idea what they are doing.Yet here you are praising them.

    AA tells you that taking pres meds will affect your sobriety.AA also tells you alcoholism is an"incurable progressive fatal disease"which is a lie.D.I.Y. therapists calling themselves"sponsers"bassically tell you that if you take prescibed medication you will die.So what will it be seeking and taking professional help and treatment or dieing of an incurable progressive fatal disease?

    AA is a dispicable organisation that has thrived on deceit and lies.Its a cult.Nothing more.I have suffered at there hands and so has my family.So to many other people.It is responsible for many suicides and family breakdowns and YOU"bless them"?

    Try finding out some information about AA yourself instead of beleiving the info AA "chooses"to give you..95% success rate at best...the rooms are full of the sickest criminals including sex offenders.Sexual preditors and worse..Guess what they are ALL anonymous.If some vunerable person is harmed by an AA member then the VICTIM will be blamed.If you try and involve the police AA members will close ranks and protect them.Even the central offices...dual diagnossis sufferers are left to fester untreated and there problems are blamed on there alcoholism...so they get told they are not working AAs mumbo jumbo religious programme....

    www.orange-papers.org this is a good place to start before you add to an already serious problem...

  • jessica menzies

    i was crying and afiad cuz if stanger come by me and my son die pls help me what i done i was so wrong.. i vry a nd afaid i need some help me and safty for me a nd my son thx..