Understanding Clients with Dual Diagnosis: Challenges and Care

1. Chapter 32Clients with a Dual Diagnosis

2. According to a report published by Journal of the American Medical Association, 37% of persons who abuse alcohol and 53% of persons who abuse drugs also have at least one serious mental illness. Of all persons diagnosed with a mental disorder, 29% abuse either alcohol or drugs. —Mental Health America, 2009

3. Chemical dependency is a serious public health problem. For people with mental illness, comorbid chemical dependency can be a catastrophic life problem. —Vaccaro, 1999

4. Learning Objectives After studying this chapter, you should be able to • Discuss the term dual diagnosis • Explain the acronyms: MICAA, MICA, and CAMI • Differentiate the two main theories related to the development of a dual diagnosis • Recognize the defining characteristics of clients with a dual diagnosis • Articulate the barriers to effective treatment of a client with a dual diagnosis

5. Learning Objectives (cont.) • Interpret the four categories that have been developed to describe the dually diagnosed client • Describe why it is difficult to assess a client with a dual diagnosis • Summarize the following phases of treatment for clients with a dual diagnosis: acute stabilization, engagement, prolonged stabilization, and rehabilitation and recovery including continuum of care • Explain why evaluation of a dually diagnosed client’s progress is an ongoing process

6. Etiology of Dual Diagnosis • Vulnerability model • Drug use contributes to mental illness. • Other factors increase the risk for mental illness. • Alcohol personality subtypes • Self-medication hypothesis • Individuals with psychiatric disorders use drugs to help them alleviate symptoms. • Self-medication leads to drug dependency.

7. Clinical Symptoms and Diagnostic Characteristics Four major categories • Primary diagnosis is mental illness; secondary diagnosis, substance-related disorder. • Primary diagnosis is substance-related disorder; secondary diagnosis, mental illness. • Mental illness and substance-related disorder coexist. • Substance-related disorder and mood disorder co-occur.

9. The Nursing Process • Assessment • Nursing diagnoses • Outcome identification • Planning interventions • Implementation • Evaluation

10. Assessment • Identify the relative contribution of the most common coexisting diagnoses: anxiety disorders, depressive disorders, personality disorders, and schizophrenia • Sources of data include the following: • Substance-related disorder assessment tools • Mental status exam • Laboratory testing • Review of court records, medical records, previous treatment records • Interview of social worker familiar with the client’s history • Observation of the client in the clinical setting • Assessment of the client’s motivation to seek treatment, desire to change behavior, and understanding of diagnosis

11. Nursing Diagnoses • Ineffective health maintenance • Disturbed thought processes • Impaired social interaction • Ineffective coping • Noncompliance • Situational low self-esteem

12. Outcome Identification Outcomes focus on the following: • Willingness to participate in treatment • Development of positive coping skills • Verbalization of feelings of increased self-worth • Development of appropriate social skills • Desire to establish and maintain contact or relationship with a professional in the community • Desire to socialize in drug- and alcohol-free environments

13. Planning Interventions Interventions are based on the individual’s needs considering the following: • The type of substance-related disorder involved • The presence or absence of cognitive impairment • The ability to process abstract concepts • Motivation for treatment • The availability of social support • The necessary treatment setting to address clinical symptoms

14. Implementation • Acute stabilization • Engagement • Prolonged stabilization • Rehabilitation and recovery

15. Evaluation Evaluation focuses on the following: • Compliance by the client • Stated outcomes • Effectiveness of interventions • Progress the client is making

16. CAMI Dual diagnosis MICA MICAA Persuasion Self-medication hypothesis Vulnerability model Key Terms

17. Reflect on the chapter-opening quote by Vaccaro. Explain your interpretation of the phrase “catastrophic life problem.” What nursing challenges do you think you would encounter if you were to develop a nursing plan of care for such a client? Do you feel adequately prepared to provide care for such a client? Explain your answer. ? Reflection