The Dual pathology Is the concurrence in the same individual of, on the one hand, a disorder by substance use and on the other hand, a comorbid psychiatric disorder.
The prevalence of this comorbid 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 may be to a substance or behavioral ( Gambling ). With regard to substances, they can be accepted culturally as the Xanthines (Coffee, tea), the alcohol Or tobacco or those not accepted as the Cannabis , the Opiates Or the Stimulants .
On the other hand, mental disorders are usually mood disorders (eg Major Depression or Bipolar disorder ), anxiety disorders (for example Generalized anxiety disorder or Social Anxiety Disorder ), Personality disorders Psychotic Disorders or Deficit Disorder of attention (ADHD).
The importance of such comorbidity has been evidenced in numerous studies because of the influence it has on clinical treatment, for the Evolution of both disorders and the costs it generates.
He 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 affects public health. Within the general population the percentage of people Consume or have consumed some kind 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 general population and clinical population have shown that the comorbidity between a mental disorder and a consumption disorder of Substances is between 15 and 80%.
It is also noted that about 50% of people with mental disorders meet criteria for substance use disorder in some Momentum throughout its life cycle.
About 55% of adults with a substance use disorder also had a diagnosis of psychiatric disorder before 15 years.
In addition, several studies have shown that the prevalence of comorbidity in psychiatric patients of substance use disorders is Higher than those of 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 admitted to a psychiatric hospital They presented at the same time a disorder by substance consumption.
A large number of epidemiological and clinical studies since the 1980s have shown that the incidence of psychiatric disorders is Higher in subjects with substance use disorders.
Likewise, patients with psychiatric disorders also have a higher propensity or vulnerability to use of psychoactive substances.
The dual patients present seriousness from the clinical and social point of view.
From the health system must face the double need they present: on the one hand, to treat from mental health their psychiatric disorder; by Another, from drug addiction, attend to their addiction.
Dual Patient Profile
Patients with dual pathology, compared to those with only a substance use diagnosis or only a mental disorder, usually require Greater hospitalization and more frequent emergency care.
In addition, they imply an increase in health spending, greater medical comorbidity, higher rates of suicide, poor adherence to treatment and results Are scarce.
They also present greater unemployment, marginalization, disruptive and risky behaviors. In addition, increased risk of infections such as immunodeficiency virus Human ( HIV ), Hepatitis, etc., and more self and heteroaggressive behaviors.
Very often they lack social support networks, live in circumstances that we may consider stressful, suffer from several Drug addiction (Pattern of Poly-smoking) and have a high risk of homelessness.
They often present lack of awareness of illness, difficulty to assume and communicate that they present an addiction. In addition, they are usually identified with only One of the disorders, drug addiction or psychiatric disorder.
They have a high rate of failures in previous therapeutic interventions and are very likely to have 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 tend to worsen social adjustment, aggravate their maladaptive behavior and 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 drugs act on the Central Nervous System And its effects may seem like symptoms typical of some mental disorders.
For example, him insomnia That generates a drug can be confused with the one that is proper to a Depression Major disorder, so that differentiate symptoms Psychopathological effects of drugs independently can be complicated.
In addition, we must take into account 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 greater proportion of males, Number of unmarried individuals or presence of a greater number of crimes with legal repercussions.
Other studies have also found a higher prevalence of low socioeconomic level or lower level of studies.
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 leading cause of morbidity and mortality in the Western world and has Repercussion in a large number of pathologies (cardiovascular, respiratory...).
After this, alcohol, cannabis and cocaine are the most commonly 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 the schizophrenia , The most commonly consumed drugs are alcohol and cannabis, while Cocaine is consumed by a smaller percentage of patients with schizophrenia.
However, in the Schizophreniform psychosis , For example, the pattern changes and the drugs most consumed are cannabis and cocaine, alcohol having a Lower consumption by individuals with said psychiatric pathology.
There is no need to deal with drugs considered as"more problematic". The xanthines (caffeine, teina...), perhaps those considered more"normal"for the Population, can also boost the consumption of other substances.
About 66% of patients who consume lots of caffeine also consume sedatives and Hypnotic . When doses are low, xanthines produce euphoria And are reinforcing, however at higher doses can produce dysphoria and anxiety.
Causes of dual pathology
Most dual pathologists (such as Casas, year 2008) indicate that dual pathology is the result of different variables Etiological.
These are both genetic and environmental and also feed back to each other, leading to the generation of neurobiological changes in which they are created Cognitions, emotions and behaviors that give rise to the 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 hypothesis indicates that addiction as well as other psychiatric disorders are symptomatic expressions other than anomalies Neurobiological characteristics.
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.
On the other hand, another hypothesis indicates that when administering drugs in a continuous and recurrent way, through mechanisms of neurological adaptation, they originate Neurobiological changes 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 disorder.
Therefore, in dual pathology there may be several possibilities. On the one hand, the first disorder can influence when developing the second, so that, from then on, it follows its independent course 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 results in a psychotic outbreak.
In this way, drug dependence happens as a primary disorder that induces psychiatric pathology. It is the mechanism that defends the theory of The neurotoxicity.
The most frequent pictures as a result of 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, that from a mental or psychiatric disorder a consumption disorder develops Of substances.
For example, during a manic episode where the person consumes alcohol can lead to an alcohol consumption disorder.
In this case, psychopathology is the risk factor for developing a dependence on drugs. Consumption is produced to relieve different symptoms Such as depression or anxiety.
We must bear in mind that another possibility in this relationship is the fact that substance use can attenuate the psychiatric symptoms of a Disorder that is either not treated properly or may have gone unnoticed and not diagnosed.
In this case, if we treat the psychiatric disorder can disappear the consumption of substances.
It is also possible that the relationship between the two is independent. That is to say, that the same person presents a psychiatric disorder and so Independent substance use disorder. In this case, the intervention must be independent.
Finally, we must distinguish in the relationship between both, that some syndromes may be temporary psychiatric conditions and that once the Time stabilizes. This is the case of a psychosis with schizophrenia that is due to drug intoxication.
It should be borne in mind that some hypothesis also suggests that early onset of substance use is associated with a higher probability of Presenting a dual pathology in adolescence.
Different authors warn that there may be a common factor of vulnerability common to childhood, adolescence and adulthood.
In this sense, the vulnerability that leads the child to present a behavior problem, can lead him in the adolescence to present a pathology by Consumption of substances, both of which are different manifestations of the same problem.
Following the aetiology and the predisposing factors to the dual pathology, we can emphasize its multifactorial character.
On the one hand the genetic factor (temperamental) and on the other hand the environmental factor (above all, the influence of the family, which we have Argued previously that there is more tendency to consumption with a familiar pattern of consumption).
The different studies cover three areas of study in what predisposes to dual pathology: the relationship between behavior and genes, the Emotional expressiveness and the interaction between family dynamics and childhood pathology.
When a family is balanced it presents cohesion and warmth between the different members; They are able to adapt optimally to the changes that Happen throughout life.
However, families with problems are against it. With more family conflicts, this is related to the onset and greater consumption of Substances as well as conduct problems in their members.
It is also influenced by the group of equals, important at these ages, modulated by the general dynamics and leading in many cases the adolescent School failure, antisocial behavior or marginalization.
With respect to the etiology of the psychiatric disorders, the psychiatric antecedents of the parents are crucial.
For example, the problematic family context, parents with substance abuse or personality problems may be related to depressive problems, Dissociative disorder , anxiety disorders Or ADHD in children.
It is due not only to the genetic etiology but also to the influence of the environment, due to patterns of discipline and paternal modeling.
For example, interactions can be based on physical punishment, violence, etc., which facilitate early child abuse and other behaviors Antisocial
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 present the patients with substance use.
There are different factors that at the same time make this diagnosis difficult, such as the denial of drug use by the subject or Their relatives, distorted information, problems of the psychotherapist, modification of psychiatric symptoms due to consumption, and so on.
The most precise and adequate treatment to be followed by these patients, both pharmacologically and psychosocially, still has gaps.
In some cases, pharmacology applied to 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, the tolerance, the side effects, Etc., may be different.
The same is true in psychological therapy, since strategies or therapies that have been effective in dealing with addictive behavior may lack Effectiveness 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 to be useful treatments for People with dual pathology.
Also, studies indicate that patients with dual pathology should receive comprehensive care, so that Addiction and psychiatric pathology, thus ensuring long-term results.
In rehabilitation, dual pathology involves difficulties and also risks. They tend to maintain better interpersonal skills, but Drugs are less likely to recover.
Adherence to treatment and staying in a rehabilitation program is costly, so the professionals and devices they go to must be Flexible.
The strategies recommended to treat patients with dual pathology are their participation, motivation, work with the environment, employ approaches Psychoeducational, individualize the treatment, give them tools to train them and work in a coordinated manner all professionals.
Rehabilitation consists of helping the subject with tools to plan their life, helping them regain their skills and confidence in themselves. There are That help you regain your autonomy.
Including the family within the treatment of patients with dual pathology favors adherence to the treatment and fulfills it better, opens up The possibility to reduce the reactive reactivity to consumption and therefore also reduces the anxiety that makes it better to maintain the abstinence .
The treatments that can be given for the dual pathology are the parallel treatment, where at the same time it is involved in both problems.
It can be a sequential treatment, where treatment for one of the problems, usually the most serious, is Next once the first one is stable.
Finally, an integrated treatment, where both are treated but within a comprehensive program, joint and by the same team.
This last treatment is the most necessary to work both drug addiction and psychiatric psychopathology. It is encompassed from a perspective Biopsychosocial and with a multidisciplinary team.
Taking into account the basic principles of treatment, as proposed by the NIDA (National Institute on Drug Abuse), which regulates The effective treatments, the importance of the treatment is individualized and the pharmacological and psychosocial treatment is integrated.
Psychosocial treatment improves patient prognosis because there is better adherence to treatment, longer abstinence and less time Total consumption.
It should be borne in mind that efficacy and treatment depend on the severity of the psychiatric disorder, the severity of the disorder Substances and the interaction between them.
In the treatment or psychological intervention, the first part consists of stabilizing the patient, attending to the psychiatric symptoms he presents, to Those derived from addictive behavior and to complete the assessment.
The dual patient requires more attention and time, greater abilities on the part of the professional to attend and greater acceptance and tolerance.
Goals should be set that the patient can achieve, reduce consumption and increase adherence to treatment.
We must make the patient aware of his problem, work on the desire for consumption and prevention of relapse, his social support and the social skills And coping strategies.
It is key to work to improve family dynamics and rehabilitation at different levels, whether family, social, work...
The intervention must be at a motivational level, psychoeducation, socio-family and through techniques such as relapse prevention, management of Contingencies, Troubleshooting techniques And prevention of relapse.
1. Psychoeducation
It is a question of the patient knowing his illness, comply with the treatment, prevent the consumption of toxic and psychiatric symptoms, learn to manage his Symptoms and to solve and deal with problems.
It is intended to increase well-being, communication with others and 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 it depends on adherence to treatment. 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 patient families. The family feels fear, anger, culpability , etc.
It is also about working with families to work on maintenance, treatment, inappropriate behavior, and so on. Also emotional support.
Future challenges in dual pathology
Studying dual pathology in the future presents great challenges. This 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 presented.
It is necessary to know the neurobiological bases, to characterize it in a clinical and diagnostic way and to develop adequate treatments from the point of view Pharmacological, psychological and social. As well as the place where the treatment is carried out (mental health centers, addiction centers).
If we can better understand what relationships exist between the different variables that influence the development of pathologies, we can deepen the Study and design strategies to evaluate, prevent and work on the most relevant factors and reduce the incidence and morbidity of pathology Dual, substance use disorder and psychiatric disorders.
References
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