Dissertationen zum Thema „Dual Diagnose“

Section A reviews the clinical and risk implications of dual diagnosis along with the treatment context. The value of gathering firsthand accounts of service users to inform the planning and delivery of healthcare is touched on. The second part of the paper centres on theories of motivation and how they might be applied to help explain low rates of dual diagnosis treatment uptake and engagement. Finally, gaps in the literature are highlighted with recommendations for further research. Section B There is an emerging evidence base to support the use of integrated approaches that treat co-existing mental health and substance use disorders simultaneously. However, low rates of treatment uptake and engagement remain a concern. To address this, it would seem important to understand dual diagnosis treatment motivation and engagement, an area that has received little attention from the research community. The aim of this study was to explore service users’ and clinicians' understandings of how treatment motivation and its relationship with treatment engagement relate specifically to people with dual diagnosis. Transcripts from semi-structured interviews with four service users and four clinicians were analysed using narrative methodology. The study suggests that the factors underpinning treatment motivation and engagement among people viewed as having dual diagnosis are similar to those thought to be associated with addictions and mental health disorders generally although their relative influence and interaction effect might be different. It is suggested that negative perceptions of services, difficulties with trust, and therapeutic relationship are particularly important issues among dual diagnosis populations. Clinical and theoretical implications of the study are discussed in relation to the literature as well as recommendations for future research. Section C: Critical Appraisal. This paper provides a general overview of narrative research, including strengths and limitations as they relate to this study. With reference to the literature, clinical and theoretical implications are elaborated along with recommendations for future research. The author’s critical self-reflections regarding the process of initiating, carrying out and completing the study are highlighted. Following this, there is a section on the ethical considerations of the study. Finally, the measures taken to ensure the quality of the study and maximise internal consistency are presented.

Dual Diagnosis, the co-occurrence of intellectual disability and psychopathology, was evaluated in 31 individuals with 22q13 deletion syndrome. Parents filled out the Reiss Scales for Children's Dual Diagnosis, The Vineland Adaptive Behavior Scales, and the Family Quality of Life Survey in order to describe the mental health, adaptive functioning and family quality of life of the subjects. Six subjects (19.35%) met the criteria for dual diagnosis, three had significant attention problems and another four had significant withdrawn behavior. Dual diagnosis was associated with overall mental health, attention problems, withdrawn behavior, autistic symptoms, anger/self control problems and social skills. Psychotic and attention deficit symptoms were the most frequent symptoms among the Reiss scales. Psychosis was not associated with overall mental health or dual diagnosis; however, it significantly correlated with family interaction, parenting, emotional well-being and quality of life. Maladaptive behavior was marked by a significant increase in externalizing behaviors with age.
Le double diagnostic, la cooccurrence d'une incapacité intellectuelle et psychopathologique, fut évalué avec 31 individus souffrant du syndrome de délétion 22q13. Les parents ont passé le test des échelles de Reiss pour le double diagnostic des enfants, Le Vineland Adaptive Behavior Scales, et le sondage sur la qualité de vie familiale de manière à décrire la santé mentale, le fonctionnement adaptif et la qualité de vie familiale des sujets. Six sujets (19.35%) ont rempli le critère du double diagnostic, trois souffraient de problèmes d'attention significatifs et quatre autres individus souffraient d'un comportement de retrait significatif. Le double diagnostic fut associé avec la santé mentale générale, les problèmes d'attention, le comportement de retrait, des symptômes autistiques, des problèmes de colères ou de contrôle de soi et les habiletés sociales. Les syndromes psychotiques ou de déficits d'attention furent les plus fréquents dans les échelles de Reiss. La psychose ne fut pas associée avec la santé mentale générale ou le double diagnostic; cependant on observa une corrélation significative avec l'interaction familiale, le parentage, le bien-être émotionnel et la qualité de vie. Les comportements mésadaptés furent marqués par une augmentation significative de l'externalisation des comportements avec l'âge.

The dual diagnosis of learning disability and mental illness stigmatises and disenfranchises those subject to it. It silences the structural and material causes of distress, pathologises natural responses to difficult circumstances and legitimises the use of restrictive methods of governance. This study used a Foucauldian genealogical approach to explore the conditions of possibility for the emergence of dual diagnosis in Britain, its attending social practices, and the subjugated discourses that could provide alternative ways of constructing and responding to the distress that people with learning disabilities may experience. Analysis of clinical and social policy documents using Rose’s (1999) six perspectival dimensions suggested that dual diagnosis emerged within a historical context of governmental concerns regarding population control, particularly in relation to economy, productivity and social order. Distal conditions of possibility included the establishment of the state’s legal and political power over insanity; the medicalisation of idiocy and lunacy; and the emergence of disciplinary and biopolitical apparatuses of the state. The developmental (re)construction of idiocy opened up a possibility for its co-occurrence with insanity and presented a conceptual framework that would be taken up following deinstitutionalisation, when dual diagnosis offered an explanation and potential solution for the social problems caused by those who did not settle into the community as desired. Dual diagnosis is neither fixed nor inevitable; it is a ‘truth’ produced by power that has been reified and endorsed through clinical and government policy and practice. Implications for clinical practice, research and policy are discussed. It is proposed that a more helpful approach to alleviating distress, poverty and disability is to address the material and social causes and the power-networks that sustain these.

There is an increase in the number of children who are identified as gifted, and exhibit a learning disorder as well. This condition is known as dual exceptionality. However, there are few empirical studies about this topic. Therefore, the purpose of this article is to pres- ent a case study of a gifted child who was in the process of being diagnosed with Asperger Syndrome. Interviews were conducted with the child, the mother and professionals that served him. Psychological, neurological and phonological evaluations carried out with the boy were analyzed. The mother and professionals raised further explanations for the child’s behavior. The difficulties in the diagnostic process and the need for a multidisciplinary approach are explored.
Se observa un aumento en el número de niños identificados como superdotados que también tienen algún trastorno, condición conocida como doble excepcionalidad. Sin embargo, hay escasez de investigaciones sobre el tema. Luego, el objetivo es presentar un estudio de caso de un niño superdotado que se encontraba en proceso de identificación del síndrome de Asperger. Se realizaron entrevistas con el niño, la madre y los profesionales que lo asistían, y se analizaron evaluaciones psicológica, neurológica y fonoaudiológica llevadas a cabo con el chico. Madre y profesionales hacen ponderaciones acerca del diagnóstico y plantean otras explicaciones para la conducta del niño. Así, darse cuenta de las dificultades en el proceso de identificación y la necesidad del enfoque multidisciplinar para el fenómeno.
Observa-se um aumento no número de crianças identificadas como superdotadas que também apresentam algum transtorno, em uma condição que é denominada dupla excepcionalidade. Porém, há escassez de pesquisas sobre o tema. Nesse sentido, o objetivo deste artigo é apresentar um estudo de caso de uma criança superdotada que estava em processo de diagnóstico da Síndrome de Asperger. Foram realizadas entrevistas com a criança, a mãe e os profissionais que a acompanhavam, e foram analisadas as avaliações psicológica, neurológica e fonoaudiológica, realizadas ao menino. A mãe e os profissionais fazem ponderações enquanto ao diagnóstico e levantam outras possibilidades de explicação para os comportamentos da criança. Percebemse as dificuldades no processo de identificação e a necessidadede um olhar multidisciplinar sobre o fenômeno.

AN ABSTRACT OF THE THESIS OF CHAD A. PONCINIE. For the Master of Science degree in Behavior Analysis and Therapy, presented on 21 June 2013. TITLE: AN EXAMINATION OF DELAY DISCOUNTING IN SEX OFFENDERS WITH DUAL DIAGNOSES MAJOR PROFESSOR: Dr. Mark R. Dixon Discounting of delayed rewards by sex offenders with dual diagnoses was compared to discounting of delayed rewards by matched control non-offenders with dual diagnoses. All participants completed a hypothetical choice task in which they made repeated choices between 10 dollars/servings after a delay and an equal or lesser amount available immediately. The delay to the large reward was varied from 1 day to 2 years across conditions. Indifference points between immediate and delayed rewards were identified at each delay condition by varying the amount of immediate money across choice trials. Overall, those identified as sex offenders discounted the delayed reward more steeply than did the control non-offenders.

Each year millions of people face the medical decision-making cycle that comes with a diagnosis of cancer. For patients and their families, this can be a rollercoaster of confusion and fear. Researchers have indicated that the complexity of the decision-making process is underrepresented in the current approach of informed decision-making. The purpose of this study was to add to scientifically-validated research expanding the identification of factors that influence decision-making for individuals diagnosed with cancer. Fuzzy trace theory (FTT) is the dual process memory theory used as the framework for this study. Qualitative data were collected using semistructured interviews with 10 participants. The sampling strategy included purposeful sampling and snowball or chain sampling. The audio-recorded interviews were transcribed and analyzed. Software tools were used to aid in the creation of word mapping and clusters and a naming structure emerged. A comprehensive thematic analysis was completed. Participants detailed experiences with family and social dynamics, psychological or emotional stress, external influencing factors to the decision-making process, and experiences with cancer advertising. This research can create positive social change through the advancement of scientifically-validated research to support patients during the decision-making process.

Each year millions of people face the medical decision-making cycle that comes with a diagnosis of cancer. For patients and their families, this can be a rollercoaster of confusion and fear. Researchers have indicated that the complexity of the decision-making process is underrepresented in the current approach of informed decision-making. The purpose of this study was to add to scientifically-validated research expanding the identification of factors that influence decision-making for individuals diagnosed with cancer. Fuzzy trace theory (FTT) is the dual process memory theory used as the framework for this study. Qualitative data were collected using semistructured interviews with 10 participants. The sampling strategy included purposeful sampling and snowball or chain sampling. The audio-recorded interviews were transcribed and analyzed. Software tools were used to aid in the creation of word mapping and clusters and a naming structure emerged. A comprehensive thematic analysis was completed. Participants detailed experiences with family and social dynamics, psychological or emotional stress, external influencing factors to the decision-making process, and experiences with cancer advertising. This research can create positive social change through the advancement of scientifically-validated research to support patients during the decision-making process.

Dual diagnosis clients continue to have low treatment completion rates. The purpose of the current study was to understand if motivational interviewing helped to increase completion rates for clients receiving cognitive behavioral therapy (CBT). Studying the problem was necessary for identifying an evidenced-based model for mental health counselors to help clients with dual diagnoses complete CBT treatment. There were no studies available for understanding the effectiveness of motivational interviewing as a tool for improving treatment completion rates for dual diagnoses clients in intensive outpatient programs. The research question examined if motivational interviewing was effective for improving treatment completion rates for the dual diagnosis population. A quantitative methodology with a quasi-experimental design used for this study and included a paired samples t test, a chi-square test, and a logistic regression analysis. The results showed a statistically significant association between receiving the motivational interviewing techniques and completing CBT. Clients who received motivational interviewing were 4 times more likely to complete CBT treatment compared to clients who did not receive the technique. Clients with increased self-efficacy levels were 2 times more likely to complete treatment, thus addressing the problem of dual diagnosis clients having low treatment completion rates. The overall results demonstrated that clients reduced substance use relapse and recidivism improved. Completing treatment helped to reduce crimes related to drug use; it also prepared substance users for return to society as productive citizens, which promoted positive social change.

Dual Diagnosis (DD) refers to the co-existence of a Severe Mental Illness (SMI) and a Substance Use Disorder (SUD) in the same individual. The comorbid prevalence of these two diagnoses is very common, with Schizophrenia (SZ), Bipolar Disorder (BD), and Major Depressive Disorder (MDD) as the three most prevalent SMI among patients with SUD. The co-existence of SUD and these SMIs includes several clinical characteristics, related to evolution and prognosis, which may complicate a patient`s recovery from both disorders. However, nowadays there is an evident need to carry out studies that provide both theoretical and practical knowledge transferable to the clinical management of patients with DD. The present study aimed, as the first objective, to study personality characteristics in a sample of patients with SUD taking into account their comorbid SMI. We evaluated a sample of 104 male patients undergoing SUD treatment, considered in three groups according to the comorbid SMI: SZ+ Group (SUD and SZ; N=37), BD+ Group (SUD and BD, N=32), and MDD+ Group (SUD and MDD; N=35). Two instruments were used to measure personality, the Cloninger's Temperament and Character Inventory-Revised (TCI-R) and the Zuckerman-Kuhlman Personality Questionnarie (ZKPQ), both based on psychobiological models. In addition, we explored the influence of the SMI in the relationship among personality and clinical variables related to both SUD and SMI diagnoses. Our second objective was to explore the influence of DD in the coping strategies used in relation to addiction treatment. SUD treatment represents a challenging situation for all patients, but given DD clinical complications, we studied the possible differential profile in the coping strategies used between patients with SZ+ (the most prevalent diagnosis in our sample) and SUD only. To elucidate the influence of comorbidity, a sample of 89 male patients undergoing treatment for addiction was included and distributed in two groups: SZ+ Group (SUD and SZ; N=39) and SUD Group (SUD only; N=43); these patients were assessed using the Coping Strategies Inventory (CS) from Tobin and completed an exhaustive clinical evaluation as well. The main personality results indicate that patients with SZ+ are characterized by an increased anxiety and fear of uncertainty (high Harm Avoidance from the TCI-R), difficulties in persevering when facing frustration and fatigue (lower Persistence from TCI-R), and the preference for solitary activities or small groups (lower Sociability from ZKPQ). Our findings suggest that patients with SZ+ are the ones who would especially need strategies to manage negative expectations and anxiety, motivational strategies, and if possible, a gradual incorporation to the group therapy sessions used during SUD treatment. Regarding personality characteristics for patients with BD+, these are characterized by an exploratory activity in response to novel stimulation, being more impulsive, getting easily bored, and by the willingness to experiment strong emotions for the sake of these types of experiences (high Novelty Seeking from the TCI-R and Impulsivity- Sensation Seeking from the ZKPQ). In addition, BD+ diagnosis is highlighted by a higher level of worries, fears, tension, and general emotional upset (high Neuroticism-Anxiety from the ZKPQ). Therefore, patients with BD+ are the ones who would require a therapeutic approach which emphasizes impulsivity management, as well as, achieving the general activity and stimulation they require. Finally, considering patients with MDD+, these are characterized by being more pragmatic, realistic, having an unstable self-image, and an erratic world-view (lower Self-transcendence from the TCI-R). Taking also into account that in previous studies a lower Self-transcendence is linked to worse general well-being and dropping-out SUD treatment, it may be suggested that interventions with MDD+ patients could benefit from therapeutic strategies that aim to increase creativity and spirituality, which are both associated with a higher Self-transcendence. With regards to the main relationships founded among personality and SUD and SMI clinical variables, we observed that such relationships are also influenced by the type of comorbid SMI. Results from the TCI-R indicate that higher scores in Novelty Seeking for patients with BD+ are related to a higher severity of addiction. Harm Avoidance is only linked to clinical variables for patients with SZ+, with a higher Harm Avoidance in patients having a greater presence of negative symptoms and general psychopathology. While Persistence did not show any clinical implications for none of the groups, Self- transcendence only showed clinical implications for the MDD+ group, in which a later age of SUD onset is associated with a lower Self-transcendence. Regarding results from the ZKPQ, we observed a positive relationship between Neuroticism-Anxiety and manic symptoms for patients with BD+, and the number of suicide attempts for patients with SZ+. Lastly, a higher Sociability is related to a later age of SUD onset for patients with SZ+, and to a later age of SMI onset for patients with MDD+. The study about coping strategies using the CSI in patients with SZ+, revealed that they are less likely to employ Engagement Strategies (Problem Solving and Social Support) and they have a lower self-perceived capacity to cope with treatment, compared with patients with SUD only. Among patients with SZ+, a major use of the Problem Solving strategy is related to a later age of SUD onset, and the self-perceived capacity to cope with treatment is negatively linked to severity of addiction and to positive symptoms. According to normative data, both groups (SUD and SZ+) use the Disengagement Strategy of Self-Criticism frequently; although the use of Self-Criticism was lower for patients with SZ+. Additionally, a higher use of Self-Criticism is related to a higher daily amount of medications for the SZ+ group. Hence, the presence of DD is associated with a lower use of active coping strategies and points to the need of training problem solving strategies, as well as, abilities to seek for social support during SUD treatment of patients with SZ+. Working on these two strategies could potentially improve treatment adherence and therapeutic outcomes. In conclusion, the findings of this thesis showed that patients with DD have different personality characteristics depending on their comorbid SMI diagnosis. Moreover, the relationship among personality and SUD and SMI clinical variables is also influenced by the type of SMI. Our findings extend to the DD field previous data about personality dimensions as potential endophenotypes for SZ (high Harm Avoidance) and BD (high impulsivity). Likewise, we observed the potential endophenotypes for developing an addiction (high Novelty Seeking and Impulsivity-Sensation Seeking, which are suggested especially for alcohol SUD) in polydrug users, regardless of the main SUD´s substance and adding nuances according to the comorbid SMI. On the other hand, a lower use of active coping strategies in relation to addiction treatment for patients with SZ+ extends to the DD field previous observations done in patients with SUD only and with SZ. Our data point to the potential usefulness of working different aspects, related to personality and coping, during DD treatment considering the comorbid SMI. However, future research is needed to advance in those lines of research, as well as, to overcome the limitations of our work. Additional studies should include a clinical, personality, and coping assessment, and longitudinal measures combined with objective data such as genetic polymorphisms and functional neuroimaging.
El concepto de Patología Dual (PD) hace referencia a la concurrencia de un Trastorno Mental (TM) y un Trastorno por Uso de Sustancias (TUS) en una misma persona. La prevalencia conjunta de estos dos diagnósticos es muy frecuente, siendo los tres TM severos comórbidos más prevalentes en pacientes con TUS la Esquizofrenia (SZ), el Trastorno Bipolar (TB) y el Trastorno Depresivo Mayor (TDM). La coexistencia del TUS y estos TMs conlleva una serie de características clínicas, de evolución y pronóstico, que dificultan la recuperación del paciente en ambos trastornos. Sin embargo, en la actualidad existe una necesidad evidente de realizar estudios que aporten tanto conocimiento teórico como trasladable al manejo clínico de los pacientes con PD. El presente trabajo se propuso, como primer objetivo, estudiar las características de personalidad en una muestra de pacientes con TUS atendiendo al diagnóstico de TM severo comórbido. Evaluamos una muestra de 104 pacientes hombres en tratamiento para el TUS, considerados en tres grupos según el diagnóstico de TM severo comórbido: Grupo SZ+ (TUS y SZ; N=37), Grupo TB+ (TUS y TB; N=32) y Grupo TDM+ (TUS y TDM; N=35). Se utilizaron dos instrumentos de medición de la personalidad, el Temperament and Character Inventory-Revised (TCI-R) de Cloninger y el Zuckerman-Kuhlman Personality Questionnarie (ZKPQ), ambos basados en modelos psicobiológicos. Además, se exploró la influencia del TM en la relación entre personalidad y variables clínicas tanto del TUS como del TM. Nuestro segundo objetivo consistió en explorar la influencia de la PD en las estrategias de afrontamiento utilizadas en relación al tratamiento de la adicción. El tratamiento para el TUS representa un desafío para todos los pacientes, pero dadas las complicaciones clínicas de la PD se estudió el posible perfil diferencial de las estrategias de afrontamiento entre pacientes con SZ+ (diagnóstico más prevalente en nuestra muestra) y con sólo TUS. Para elucidar la influencia de la comorbilidad, se incluyó una muestra de 89 pacientes hombres en tratamiento para la adicción considerados en dos grupos: Grupo SZ+ (TUS y SZ; N=39) y Grupo TUS (N=43), a quienes se les aplicó el Coping Strategies Inventory (CSI) de Tobin junto con una exhaustiva evaluación clínica. Los principales resultados sobre personalidad indican que los pacientes con SZ+ destacan por una mayor ansiedad y temor a la incertidumbre (elevada Evitación del Riesgo del TCI-R), dificultad para perseverar ante la frustración y la fatiga (menor Persistencia del TCI-R) y preferencia por actividades en solitario o en grupos pequeños (menor Sociabilidad del ZKPQ). Nuestros hallazgos sugieren que los pacientes con SZ+ son quienes necesitarían especialmente de estrategias de manejo de expectativas negativas y ansiedad, de estrategias motivacionales y, siempre que sea posible, una incorporación paulatina a las sesiones grupales utilizadas durante el tratamiento para el TUS. Respecto a las características de personalidad de los pacientes con TB+, éstos destacan por la excitación frente a estímulos novedosos, ser más impulsivos, aburrirse fácilmente y poseer una necesidad de experimentar sensaciones fuertes por el mero hecho de vivirlas (elevadas Búsqueda de Novedad del TCI- R e Impulsividad-Búsqueda de Sensaciones del ZKPQ). Además, el diagnóstico de TB+ destaca por un mayor nivel de preocupaciones, miedos, tensión y malestar general (elevado Neuroticismo-Ansiedad del ZKPQ). Por tanto, serían especialmente los pacientes con TB+ quienes requieren de un énfasis terapéutico en el manejo de la impulsividad y en la búsqueda de la activación y estimulación que necesitan. Finalmente atendiendo a pacientes con TDM+, éstos se caracterizan por ser más pragmáticos, realistas, poseer una imagen más inestable de sí mismos y una visión más errática del mundo (menor Trascendencia del TCI-R). Considerando además que en estudios previos se ha relacionado una menor Trascendencia con peor bienestar general y con el abandono del tratamiento para el TUS, cabe sugerir que las intervenciones con estos pacientes se podrían beneficiar de incluir estrategias terapéuticas que incrementen la creatividad y la espiritualidad, ambas asociadas a una mayor Trascendencia. Respecto a las principales relaciones encontradas entre personalidad y variables clínicas del TUS y del TM, observamos que éstas también se hallan influenciadas por el tipo de TM severo comórbido. Los resultados del TCI-R indican que las puntuaciones superiores en Búsqueda de Novedad de los pacientes con TB+ se asocian a una mayor gravedad de la adicción. La Evitación del Riesgo sólo se relacionó con variables clínicas en pacientes con SZ+, siendo ésta más elevada cuanto mayor es la presencia de síntomas psicóticos negativos y de psicopatología general. Mientras que la Persistencia no mostró relaciones con variables clínicas en ningún grupo, la Trascendencia sólo mostró implicaciones clínicas en el grupo con TDM+, en el cual, una mayor edad de inicio del TUS se asoció a una menor Trascendencia. Respecto a los datos aportados por el ZKPQ, observamos una relación positiva entre el Neuroticismo-Ansiedad y la presencia de síntomas maníacos en pacientes con TB+, así como con la cantidad de intentos de suicidio en pacientes con SZ+. Finalmente, una mayor Sociabilidad se relaciona con una edad más tardía de inicio del TUS en pacientes con SZ+ y de inicio del TM en pacientes con TDM+. El estudio de estrategias de afrontamiento mediante el CSI en pacientes con SZ+ mostró que éstos utilizan con menor frecuencia estrategias de Manejo Adecuado del problema (Resolución de Problemas y Apoyo Social), y perciben que tienen menor capacidad para afrontar el tratamiento respecto a pacientes con sólo TUS. En pacientes con SZ+ un mayor uso de la estrategia de Resolución de Problemas se relaciona con una edad de inicio de TUS más tardía, y la capacidad para afrontar el tratamiento se asocia negativamente a la gravedad de la adicción y a los síntomas psicóticos positivos. Según baremos normativos ambos grupos (TUS y SZ+) recurrían muy frecuentemente a la estrategia de Manejo Inadecuado de Autocrítica, aunque su uso era menor en pacientes con SZ+. Además, una mayor Autocrítica se relaciona con más cantidad diaria de medicación en SZ+. Por tanto, la presencia de PD se vincula a un afrontamiento del tratamiento para la adicción menos activo y apunta a la necesidad de entrenar a los pacientes con SZ+ en el uso de estrategias de resolución de problemas y búsqueda de apoyo social durante su tratamiento para el TUS, pudiendo ello mejorar tanto la adherencia como la respuesta terapéutica. Como conclusión, los hallazgos de esta tesis muestran que los pacientes con PD difieren en las características de personalidad según su diagnóstico de TM severo comórbido. Además, la relación entre la personalidad y las variables clínicas del TUS y TM también se halla modulada por el tipo de TM. Nuestros resultados extienden al ámbito de la PD los datos previos sobre dimensiones de personalidad como posibles endofenotipos de la SZ (elevada Evitación del Riesgo) y del TB (elevada impulsividad). Así mismo, los posibles endofenotipos de personalidad para el desarrollo de la adicción (elevadas Búsqueda de Novedad e Impulsividad-Búsqueda de Sensaciones, que se sugieren especialmente para el TUS por alcohol) los observamos en pacientes policonsumidores, con independencia del tipo de sustancia principal del TUS, añadiendo matices según el TM severo comórbido. Por otra parte, el menor uso de estrategias de afrontamiento activas en relación al tratamiento de la adicción en pacientes con SZ+ extiende al ámbito de la PD observaciones previas realizadas en pacientes con TUS y con SZ. Los datos apuntan a la posible utilidad de trabajar aspectos diferenciales, relacionados con la personalidad y el afrontamiento, durante el tratamiento de la PD atendiendo al TM severo comórbido. Sin embargo, para poder progresar en esta área y superar las limitaciones de nuestros estudios, se requieren futuras investigaciones que, junto con la evaluación clínica, de personalidad y afrontamiento, incluyan registros longitudinales y medidas objetivas como polimorfismos genéticos y de neuroimagen funcional.

Comorbidity between Axis I mental disorders and substance use disorders range from 5%--60% (Farrell, 1998; Fowler, 1998). It has been suggested that dually diagnosed patients are inadequately treated for both disorders and that they are problematic from a diagnostic, clinical management and economic perspective. Dual Diagnosis (DD) maybe associated with a number of issues including increased aggression, increased non-compliance with medication (Swartz, 1998), and exacerbated psychopathology (Tomasson, 1997). However, contradictory evidence has also been found (Leon, 1998), which suggests that patients with DD may be a higher functioning population of mentally ill patients. The objectives of the present study were to determine the prevalence and clinical characteristics of dual diagnosis patients in a chronic psychiatric population. A sample of 217 patients with schizophrenia spectrum disorders was randomly sampled from the psychiatric facilities of the Montreal General Hospital. Almost half of the sample presented with comorbid addictive disorders; the most common drugs abused were alcohol, cannabis and cocaine. Those patients who had a lifetime diagnosis of substance abuse or dependence were more likely to be male, had a more severe course of psychiatric illness, higher rates of psychiatric symptomology, were more likely to be tobacco smokers and had higher rates of non-compliance with psychiatric medications. Further analyses revealed lower levels of social support and more legal problems in patients with DD, all of which may negatively impact on the quality of care for dual diagnosis patients in the clinical setting.

Dual Diagnosis (DD) is the co-occurrence of a Severe Mental Illness (SMI), commonly a major psychotic or affective disorder, and a Substance Use Dependence Disorder (SUD). It is a highly prevalent disorder with a large impact in clinical and health care systems due to the complications arising from the comorbidity between both conditions. The aim of this work is twofold: the study of the cognitive performance and the Health Related Quality of Life (HRQOL) in patients with DD. The first one, because few studies have examined this question and its assessment is of great interest, since cognitive functioning is related to the clinical course and may even be a predictor of failure or success of the therapeutic interventions. Although major cognitive impairments can be expected in DD due to the additive effects of both psychiatric disorder and SUD, a wide review of published results on the scientific literature suggest that their cognitive functioning depends, among others, on the main substance of choice, the assessed cognitive domain and the age of the participants. Thus, we focus on the assessment of the executive functioning on one hand, and on the domains of attention, memory and speed of processing on the other, in a sample comprised by subjects with schizophrenia and cocaine dependence (SZ+; n = 30) compared to subjects with schizophrenia without SUD history (SZ-; n=30) and to cocaine dependent subjects without psychiatry comorbidity (COC; n=35). Although in the last decades there has been an increased interest in the Quality of Life as an assessment measure as well as an indicator of the effectiveness of interventions in both SMI and SUD, few studies had focused on DD. For this reason, the second objective of this work was to assess HRQOL in a group with DD (n = 35) and compare it to a group with SMI (n=35) and to another one with SUD (N=35) without comorbidity. Regarding the cognitive functioning, the results showed a similar pattern of performance in the SZ+ and COC groups in neuropsychological tasks related to executive functions, being their performance better than the SZ- group. This may suggest that patients with SZ+ have higher cognitive skills than the SZ- ones. Therefore, the SZ+ patients may be a subgroup of SZ with lower biological vulnerability to develop the illness and maybe, a better psychosocial premorbid functioning, making them more able to acquire the illegal substance of abuse. In the domains of attention, memory and speed of processing, the COC group performed better than both SZ+ and SZ- groups, without differences between them. However, the age was negative related to the cognitive performance in the SZ+ group. So, the older SZ+ showed worse cognitive functioning. Otherwise, the SZ- patients showed a stable cognitive functioining regardless of the age. This, in agreement with the idea of an additional cognitive impairment to the psychiatric disorder manifested in older SZ+ patients because of the long term expression of the neurotoxic consequences of consumption. Concerning HRQOL, all the groups showed lower scores compared with the normative Spanish data. The DD group showed the worst scoring in most of assessed scales and in the mental domain, while the SUD group obtained the best, and the SMI obtained intermediate scores. The worse state in the mental domain appeared strongly related to the number of suicide attempts, daily intake of medication and to the caffeine consumption, only in the DD group. The systematic assessment of the HRQOL status could be a useful tool in the detection of specific care areas, helping to improve the treatment goals as well as an assessment measure of the effectiveness of interventions applied to DD patients. Overall, our results suggest particular characteristics in subjects with DD regarding cognitive performance and HRQOL status, which make them different to the subjects with SMI and SUD. This demonstrates the interest to study DD as a specific diagnostic entity. However, further research in this field, incorporating long term measures and biological parameters, could help to a better understanding of the current knowledge in DD and to increase the benefits in the clinical management of these patients.
Se denomina Patología Dual (PD) a la coocurrencia de un Trastorno Mental Severo (TMS), especialmente de la esfera psicótica y/o afectiva y un trastorno por uso de sustancias (TUS). Se trata de un trastorno de elevada prevalencia, con una gran repercusión clínica y asistencial debido a las complicaciones asociadas a la comorbilidad entre ambas patologías. El presente trabajo se propuso dos objetivos, estudiar el rendimiento cognitivo y la calidad de vida Relacionada con la Salud (CVRS) en pacientes con PD. El primero dada la escasez de estudios y la importancia de su evaluación, puesto que el funcionamiento cognitivo se relaciona con el curso clínico de la PD y puede incluso ser un factor predictivo del éxito o fracaso de las intervenciones terapéuticas. Si bien cabrían esperar importantes déficits cognitivos en los pacientes duales, debido a los efectos aditivos del trastorno psiquiátrico y del TUS, una revisión bibliográfica exhaustiva de los principales resultados publicados sugiere que su funcionamiento cognitivo depende, entre otros factores, de la sustancia principal de abuso, del dominio cognitivo evaluado y de la edad de los participantes. Así, nos centramos en evaluar el funcionamiento ejecutivo por una parte y los dominios de atención, memoria y velocidad del procesamiento de la información por otra, en una muestra de pacientes con esquizofrenia y dependencia a la cocaína (SZ+; n=30) comparados con esquizofrénicos sin historia de TUS comórbido (SZ-; n=30) y un grupo con dependencia a la cocaína sin comorbilidad psiquiátrica (COC; n=35). Aunque en las últimas décadas se ha producido un aumento en el interés de la Calidad de Vida como medida de evaluación y como un indicador de la eficacia de las intervenciones en los TMS y en los TUS, los estudios en la PD son pocos. El segundo objetivo de este trabajo fue evaluar la CVRS en pacientes con PD (n=35), con sólo TMS (n=35) y con sólo TUS (n=35). Los resultados del rendimiento cognitivo mostraron un patrón de actuación similar en los grupos SZ+ y COC en tareas neuropsicológicas dependientes del funcionamiento ejecutivo, siendo el rendimiento de ambos grupos mejor que el del grupo SZ-. Esto podría sugerir que los pacientes SZ+ poseen mayores habilidades cognitivas que los SZ-, y por tanto, pudiendo ser un subgrupo de SZ con menor vulnerabilidad biológica a desarrollar la enfermedad, presentando mayores habilidades ejecutivas y quizás, un mejor funcionamiento psicosocial premórbido que les haría más hábiles para adquirir las sustancias ilegales. En los dominios de atención, memoria y velocidad del procesamiento de la información, el grupo COC presentó un mejor rendimiento que los grupos SZ+ y SZ-, los cuáles no presentaron diferencias entre ellos. Sin embargo, la edad mostró una asociación negativa con la ejecución cognitiva en el grupo SZ+, los pacientes de mayor edad mostraban peor rendimiento cognitivo. En cambio, el grupo SZ- presentaba un déficit cognitivo estable independiente de la edad. Esto es coherente con la idea de un déficit cognitivo adicional al del trastorno psiquiátrico manifestado en los pacientes duales de mayor edad, debido a la expresión a largo plazo de las consecuencias neurotóxicas del consumo. En cuanto a la CVRS, todos los grupos aportaron peores puntuaciones de CVRS respecto a los valores normativos españoles. En la mayoría de subescalas y especialmente en el dominio de salud mental, el grupo con PD mostró las peores puntuaciones, el grupo TUS las mejores y el grupo TMS se situó en una posición intermedia. El peor estado en el dominio mental de la CVRS apareció estrechamente relacionado con los intentos de suicidio, el número de medicamentos diarios y el consumo de cafeína en el grupo PD. La evaluación sistemática del estado de la CVRS puede ser útil en la detección de áreas de atención específica para los objetivos del tratamiento, así como medida de la eficacia de las intervenciones aplicadas a la PD. Nuestros resultados sugieren características de rendimiento neuropsicológico y de CVRS particulares de los pacientes con PD, que los diferencian de aquellos con diagnóstico sólo de TMS o TUS. Ello evidencia el interés de estudiar la población dual como una entidad diagnóstica específica. Sin embargo, se requieren investigaciones futuras que progresen en esta línea de trabajo incorporando además, parámetros neurobiológicos y medidas longitudinales, lo que puede ayudar a mejorar el conocimiento actual de la PD y revertir en beneficios para el manejo clínico de los pacientes.

Conventional imaging techniques for cancer detection have difficulty finding small, deep tumors. Single-detector radiation probes have been developed to search for deep lesions in a patient who has been given a tumor-seeking radiopharmaceutical. These probes perform poorly, however, when the background activity in the patient varies greatly from site to site. We have developed a surgical dual-detector probe that solves the problem of background activity variation, by simultaneously monitoring counts from a region of interest and counts from adjacent normal tissue. A comparison of counts from the detectors can reveal the class of tissue, tumor or normal, in the region of interest. In this dissertation we apply methods from statistical decision theory and derive a suitable comparison of counts to help us decide whether a tumor is present in the region of interest. We use the Hotelling trace criterion with a few assumptions to find a linear discriminant function, which can be reduced to a normalized subtraction of the counts for large background count-rate variations. If area under the ROC curve is our figure of merit, the likelihood ratio is the optimum discriminant. We model likelihood functions of the data given the "tumor" and "no-tumor" hypotheses, and calculate the likelihood ratio. Using a spatial response map of the dual probe, a computer torso phantom, and estimates of activity distribution, we simulate a surgical staging procedure to test the dual probe and the discriminant functions. Results of the simulations show that the dual probe effectively solves the problem of background activity variations when used with any of the discriminant functions derived in this dissertation.

Dual-diagnosed female offenders (DDFOs) present direct care providers with complex psychosocial needs and challenges that result in a serious lack of motivation to attain, sustain, and continue treatment after release from prison. Unsuccessful treatment of DDFOs represents a significant public health and safety risk including continuing criminal acts, increased health care costs, accidents related to substance abuse, and poor reintegration. Through in-depth semistructured interviews with direct care providers, this phenomenological study's focus was on examining the motivational facilitators associated with treatment adherence, barriers to treatment adherence, and approaches for enhancing treatment motivation. Nine major themes emerged from this research, including the importance of an empathetic approach and a strong therapeutic alliance as motivational facilitators; lack of insight and acceptance of the need for treatment, lack of resiliency, and the role of external system factors in barriers to treatment adherence; and using an empathetic approach, building rapport, instilling hope, and avoiding confrontation as approaches for enhancing treatment motivation. These findings may inform theory and practice related to the treatment of DDFOs in U.S. prisons. These findings contribute to social change by identifying outcomes related to treatment attendance, continuity of care, and completion and may help reduce recidivism associated with DDFOs, decrease costs of care, and lower public risks such as accidents related to substance use. The study provides reference points that may inform recommendations to state correctional departments regarding effective programming strategies for DDFOs.

Dual-diagnosed female offenders (DDFOs) present direct care providers with complex psychosocial needs and challenges that result in a serious lack of motivation to attain, sustain, and continue treatment after release from prison. Unsuccessful treatment of DDFOs represents a significant public health and safety risk including continuing criminal acts, increased health care costs, accidents related to substance abuse, and poor reintegration. Through in-depth semistructured interviews with direct care providers, this phenomenological study’s focus was on examining the motivational facilitators associated with treatment adherence, barriers to treatment adherence, and approaches for enhancing treatment motivation. Nine major themes emerged from this research, including the importance of an empathetic approach and a strong therapeutic alliance as motivational facilitators; lack of insight and acceptance of the need for treatment, lack of resiliency, and the role of external system factors in barriers to treatment adherence; and using an empathetic approach, building rapport, instilling hope, and avoiding confrontation as approaches for enhancing treatment motivation. These findings may inform theory and practice related to the treatment of DDFOs in U.S. prisons. These findings contribute to social change by identifying outcomes related to treatment attendance, continuity of care, and completion and may help reduce recidivism associated with DDFOs, decrease costs of care, and lower public risks such as accidents related to substance use. The study provides reference points that may inform recommendations to state correctional departments regarding effective programming strategies for DDFOs.

Recent publicity has focused on the problems created by the usage of illicit drugs in the community. The growing use of illicit drugs throughout the Grampians region and the lack of resources and professional services available to regional and rural areas raise many questions as to treatment options and the accessibility and appropriateness of drug and alcohol and mental health services. Despite the fact that mental health professionals in rural/regional areas are expected to deliver the most appropriate care to individuals with a comorbid drug and alcohol and psychiatric disorder, a number of these rural/regional mental health professionals have limited preparation and experience in dealing with dual diagnosis issues. This phenomenological study focuses on the area of dual diagnosis, specifically the experiences of health professionals who care for clients diagnosed with a serious mental illness and a coexisting drug and alcohol disorder. Results are described in the form of four themes, which emerged from data collected during in-depth interviews with 13 mental health professionals who care for clients with a dual diagnosis. The themes captured in this research will be described using metaphors as headings. The first theme Sink or swim represents mental health professionals’ initial preparation to care for this group of complex clientele. Treading water symbolises mental health professionals’ endeavours to keep their head above water and reflects on their feelings while endeavouring to do so. Rowing against the tide describes mental health professionals’ understanding of clients’ drug misuse, which impacts greatly on the level of care.
Master of Nursing

Many forensic patients are diagnosed with both a ‘serious mental illness’, such as ‘schizophrenia’ and a ‘substance use disorder’. This is referred to as dual diagnosis, and is socially situated: distress, substance use and recovery appear linked to interpersonal and social context. Forensic services aim to facilitate patients’ recovery from mental health difficulties, substance use and offending, historically from a biomedical perspective. However, recently they have moved towards a ‘recovery model’ approach. Peer support is a cornerstone of the recovery model: Those with shared experiences of mental distress, treatment and recovery can help reduce stigma and foster recovery in each other. This study aimed to explore the role of naturally occurring peer relationships in recovery for forensic patients. Ten male forensic patients were interviewed across fifteen interviews which were analysed using constructivist grounded theory. The analysis constructed a model of recovery as an individual journey intertwined with an interpersonal journey, comprising four stage-categories, and a fifth category representing social processes between peers. Participants actively negotiated peer relationships in different ways throughout recovery. Constructing oneself in relation to peers influenced participants’ sense of self and recovery. Some features of the forensic environment complicated recovery, and stigma was reproduced between peers. Building on patients’ use of comparison, effective peer relationships and coping strategies could help facilitate recovery. Continuing to shift towards a recovery approach within forensic services could reduce some of the identified barriers to recovery for forensic patients. Recommendations for forensic services, Counselling Psychologists and Counselling Psychology training programmes are made.

Thesis (Ph. D.)--West Virginia University, 2005.
Title from document title page. Document formatted into pages; contains ix, 122 p. Includes abstract. Includes bibliographical references (p. 98-114).

Syftet med denna C-uppsats har varit att få en ökad förståelse i hur vårdgivare arbetar med människor i ett mellanrum mellan två kategorier samt att belysa den problematik som finns med att kategorisera människor som dubbeldiagnos. Dubbeldiagnos är en kategorisering som ibland skapar problem som gör att dessa klienter hamnar i ett mellanrum mellan kommunen och landstinget. Denna studie är baserad på en kvalitativ metod med grundad teori som forskningsdesign. Intervjuer har gjorts med respondenter från psykiatrin, boendeverksamhet, öppenvårdsverksamhet och socialtjänsten. Resultatet tyder bland annat på att det som är viktigast i arbetet med dubbeldiagnoser är samverkan mellan vårdgivarna. Diagnosen kan även medföra att klienterna känner sig stämplade. Den viktiga eftervården brister i kvalité som bottnar i de bristande resurser som finns. Detta resultat diskuteras i diskussionen med hjälp av teorier om social kategorisering och typifiering.

Mental health and substance abuse treatment systems have a history of incompatible philosophies and conflicts that have been associated with poor treatment outcomes for persons dually diagnosed. The purpose of this study was to determine whether or not there are differences in attitudes between mental health and substance abuse professionals toward the dually diagnosed client and whether or not academic discipline, levels of training and experience, occupation, and amount of contact affect the attitudes of these professional groups. A non-experimental survey research design was used for this study, and data were collected by means of a revised Opinions About Mental Illness (OMI) survey instrument and supplemental demographic questionnaire. The modified OMI instrument was piloted by a panel of subject matter experts experienced in the treatment of persons who are dually diagnosed in which they rated each item for favorableness to concepts of dual diagnosis. The modified OMI survey and a demographic questionnaire were administered to a sample consisting of mental health and substance abuse professionals employed at a local community mental health center. A total of 86 respondents representing 95% of the sample population completed the modified OMI survey and demographic questionnaire. Data were analyzed using descriptive, independent sample t-test, and multiple analysis of variance (MANOVA) statistics. Results revealed no statistically significant differences in attitude between mental health and substance abuse professionals toward dually diagnosed clients. Analysis of the independent variables academic discipline, level of training and experience, occupation, and amount of contact demonstrated no significant interaction effects between mental health and substance abuse professionals. Despite the absence of statistically significant differences in attitude between the mental health and substance abuse professionals, the similarities may be significant in terms of the psychological value for building positive relationships. The atmosphere of agency culture and the significance of co-location of mental health and substance abuse professionals were also potentially important factors in the outcome of the present study.
Ed. D.

Legislative changes in line with changing societal perspectives have resulted in increased service pressure on primary health practitioners to take further responsibility for the assessment and treatment of co-morbid psychiatric disorders in individuals with intellectual disability (ID) and for secondary and tertiary level services to reduce waitlists. The unique attributes of the ID population and a core lack of training for health professionals in the ID field has resulted in a large number of practitioners feeling under-trained and under-resourced to carry out this role effectively, to the potential detriment of the ID population. The challenges health practitioners experience when diagnosing co-morbid mental health disorders in individuals with ID and how they overcome these challenges was explored in this study. Participants were health practitioners of varying professions, including Psychiatrists, Clinical Psychologists and General Practitioners. Health practitioners completed an online survey and/or partook in a focus group or individual interview. The method used in this research was thematic analysis. The study found that health practitioners use holistic and contextual approaches to carry out assessments of individuals with ID, utilise ID specific tools, and liaise with experienced, specialised health practitioners as ways of dealing with the complexity of diagnosing co-morbid mental health difficulties in individuals with ID. In addition, it is recommended that more training in the ID area is provided for health practitioners, particularly for GPs in light of recent policy changes with emphasis of assessment and treatment occurring at the primary health level and for best practice guidelines to be developed. A further research project is suggested, exploring specific challenges facing GPs in this area of practice.

The research focus for this study was to examine the perspectives of social workers on clients’ ability to maintain sobriety. The primary question that was addressed is if social workers believe that a person can continue to maintain sobriety after treatment. The secondary question was whether having a dual diagnosis affects these beliefs. The sampling strategy that was used was the maximum variation sampling, and qualitative data gathering was used for this study through face-to-face interviews between the researcher and the social workers on an individual basis. Each interview was audio-recorded on a digital device. There are a total of eight participants in the study. The study found that there existed a strong connection between maintaining sobriety and having a healthy support system. The study also revealed that professional burnout had a significant effect on the treatment of the client. Finally, the findings of the study point to the importance of psychotherapy in treatment of chemically dependent patients. Overall results suggest the strong need for healthy support systems to maintain sobriety and the necessity of exploring methods to better prevent professional burnout. Results also imply the need for continued research in the area of substance abuse and how to better promote sobriety within the community.

Se denomina Patología Dual (PD) a la coexistencia entre un Trastorno por Uso de Sustancias (TUS) y un Trastorno Mental Severo (TMS), especialmente de la categoría de patología psicótica y afectiva. La PD se halla asociada a problemas clínicos y sociales incrementados a los que pueden darse en la presencia sólo de un trastorno, es más frecuente en los varones y la prevalencia de comorbilidad entre TMS y TUS en población psiquiátrica es superior al 50%. Encontrar factores explicativos de la PD es una tarea sumamente complicada puesto que en ella se hallan implicados tanto factores biológicos como psicosociales. Pero el progreso en este ámbito es de vital importancia para mejorar no sólo el conocimiento básico sino la eficacia del tratamiento y la prevención de recaídas. Nuestra investigación se centra en analizar las características de personalidad, las estrategias de afrontamiento y la calidad de vida en pacientes con diagnóstico PD, comparándolos con pacientes diagnosticados sólo de TUS y sólo de TMS. La selección de variables a estudiar se fundamenta en una extensa revisión bibliográfica y en la posible aportación aplicada que puede derivarse de nuestros resultados. Para el estudio de la personalidad se han seleccionado los modelos psicobiológicos de Cloninger y Zuckerman, junto a un estudio más específico de la impulsividad con el modelo de Dickman. Para la evaluación del afrontamiento ante las situaciones de estrés, considerado un factor protector en situaciones de riesgo psicosocial y abuso de drogas, hemos seleccionado el inventario de estrategias de afrontamiento desarrollado por Tobin. Finalmente, para evaluar la calidad de vida relacionada con la salud de los pacientes se utilizó la escala SF-36 de Ware & Sherbourne. La muestra seleccionada se hallaba compuesta por 102 pacientes varones en tratamiento, de edad comprendida entre los 25 y 55 años, distribuidos en tres grupos: dual (n=34), TUS (n=34) y TMS (n=34). Los pacientes se registraron tras un mínimo de 6 meses en abstinencia y estabilizados de su TMS. Los grupos dual y TMS estaban constituidos por 20 pacientes con diagnóstico de esquizofrenia y 14 de trastorno depresivo mayor respectivamente, por lo que comparamos si la presencia del tipo de TMS podía ser un factor relevante en aportar diferencias en las variables estudiadas y en la comorbilidad. Los resultados confirman la existencia en la PD de un patrón clínico y social que genera mayores complicaciones, como son la elevada tasa de intentos de suicidio o la mayor cantidad de psicofármacos administrados. La PD es un factor de riesgo para el inicio precoz del consumo de drogas, desarrollando con mayor facilidad adicción a múltiples sustancias, especialmente alcohol, cocaína y cannabis. Presenta un perfil de personalidad caracterizado por elevada búsqueda de sensaciones e impulsividad, ambos rasgos característicos del TUS y considerados un factor de riesgo para el inicio del consumo y la peor respuesta al tratamiento. De la misma manera, se percibe en ellos dificultades para tolerar la frustración (baja persistencia) y la tendencia a evitar los estímulos aversivos (elevada evitación del daño), características asociadas al TMS. La presencia de esquizofrenia, especialmente en los duales, en comparación con la depresión, se ha relacionado con rasgos de personalidad más extremos como la elevada búsqueda de sensaciones, dependencia a la recompensa e impulsividad y menor capacidad para responsabilizarse de sus propias decisiones. En cuanto a las estrategias de afrontamiento, se corrobora en los pacientes duales un mayor uso de estrategias inadecuadas, principalmente las centradas en la emoción, ocasionado por la escasez de habilidades para afrontar los problemas en comparación con los pacientes TUS y los TMS. También observamos un mayor deterioro en la calidad de vida de los pacientes duales, tanto en el plano físico como mental, con mayores interferencias de la patología en su vida diaria y unas expectativas futuras de recuperación menores. Nuestra investigación aporta información relevante sobre las características de personalidad y las estrategias de afrontamiento, así como de la calidad de vida relacionada con la salud de pacientes con diagnóstico de PD y el posible peso específico con el que contribuyen a ellas el TUS y el TMS (esquizofrenia o depresión). Sin embargo, se requieren más estudios en el futuro que profundicen en este campo de trabajo en beneficio del abordaje terapéutico y el pronóstico de los pacientes con PD.
Dual Diagnosis (DD) is the coexistence of Substance Use Disorder (SUD) and Severe Mental Illness (SMI), especially when these are in the category of psychotic and affective pathologies. DD is associated with increased clinical and social problems compared to those seen in the presence of SUD and SMI alone, it is more frequent in males and its prevalence in the psychiatric population is greater than 50%. Factors underlying DD are extremely difficult to find because DD implies not only biological elements but also psychosocial ones. Advances in this field are key to improve not only our basic knowledge about mental disorders but also their treatment efficiency and relapse prevention. Our research focused on the analysis of personality characteristics, coping skills and quality of life in subjects with DD, compared to patients with either SMI or SUD. We selected these study variables based on both an extensive bibliographic review and the possible benefit to these that can be generated from our results. For the study of personality characteristics we selected the Cloninger and Zuckerman psychobiological models with a more specific analysis of impulsivity based on the Dickman model. To evaluate coping skills in stressing situations, considered as protective factors in psychosocial risk situations and substance abuse, we selected the Coping Strategies Inventory developed by Tobin. Finally, the SF-36 scale of Ware & Sherbourne was used to evaluate quality of life. Our sample was composed of 102 males under treatment, between 25 and 55 years old and distributed in three groups: DD (n=34), SUD (n=34) and SMI (n=34). These subjects were abstinent for a minimum 6 months and stable for their SMI. The DD and SMI groups included 20 patients diagnosed with schizophrenia and 14 with major depression, which allowed us to assess whether the studied variables and SUD or SMI comorbidity can be affected by the type of SMI. Our results confirmed the existence of a clinical and social pattern in DD which results in an increased number of complications such as higher rate of suicidal attempts or quantity of administered psychopharmacs. DD is a risk factor to early drugs intake, being multi-drug addiction (alcohol, cocaine and cannabis especially) the most common feature. The DD group presented a personality profile characterized by higher sensation seeking and impulsivity, both traits typical of SUD and considered a risk factor to early drugs intake and worse treatment response. DD showed problems with frustration tolerance (low persistence) and tendency to avoid aversive stimulus (high harm avoidance), traits associated to SMI. The presence of schizophrenia, especially in DD, in comparison to depression, has been related to more extreme personality traits such as high sensation seeking, reward dependence and impulsivity and low capacity to take responsibility for their own decisions. A greater use of dysfunctional coping skills by DD patients was confirmed, mainly the emotional ones, produced by the lack of abilities to solve problems in comparison to SUD and SMI patients. We also observed worse quality of life in DD patients, both physical and mental dimension, with higher interference of the pathology in the daily life and lower future prospects of recovery. Our investigation provides relevant data about personality traits, coping skills and quality of life related to health of patients with DD and to the specific weight with which SUD and SMI (schizophrenia or depression) contribute to it. However, in the future more studies are needed to improve the treatment and prognosis of DD patients.

The goal of this study was to determine the bio-psychosocial treatment needs of dual diagnosis patients with depressive episodes and alcohol misuse. In order to achieve this goal, a qualitative research approach was adopted to gain a holistic understanding of dual diagnosis, as well as to explore and to describe the bio-psychosocial treatment needs of these individuals. This research study aimed to contribute towards solving a practical problem in practice by offering recommendations for a multidisciplinary team approach with regard to the treatment of patients diagnosed with depressive episodes and alcohol misuse in South African treatment centres. To this end, the collective case study design guided the research study. A two-stage sampling strategy was implemented in the study. Firstly, purposive sampling was used to identify potential participants, and it was followed up with, secondly, volunteer sampling to recruit 10 individuals with co-occurring depressive episodes and alcohol misuse from a private psychiatric clinic in Pretoria, which formed the research sample. Furthermore, a semi-structured one-on-one interview, guided by questions contained in an interview schedule, was used as a data collection method. The researcher implemented the qualitative data analysis process of Creswell (1998, in Schurink, Fouché & De Vos, 2011) to extrapolate themes and sub-themes from the raw data through thematic analysis. The trustworthiness of the data interpretation was confirmed through peer debriefing, member checking, as well as the assurance of confidentiality. An analysis of two different sources of data, namely the literature review and interviews, was used to answer the following research question: What are the bio-psychosocial treatment needs of dual diagnosis patients suffering from depressive episodes and alcohol misuse? The key findings indicated that persons suffering from a dual diagnosis of depressive episodes and alcohol misuse have idiosyncratic biological, psychological and social treatment needs. On a biological level it was found that patients with a dual diagnosis lead a less active and an unhealthy lifestyle and are therefore more prone to the development of chronic illnesses, such as hypertension and cardiovascular disease. It was also found that these individuals exhibit addictive behaviours apart from the alcohol misuse. With regard to psychological needs, the research found that dual diagnosis patients experience difficulties in expressing their needs and emotions to others. In this regard the research indicated that these individuals have poorly developed coping mechanisms and limited resources for gaining an improved sense of well-being. Identified areas in which these individuals may need assistance on a psychological level include: general coping mechanisms, communication skills, problem solving skills, and conflict management. With regard to violent and aggressive behaviour, it was found that these individuals are more likely to internalise their frustration and aggress towards themselves. On a social level it was found that individuals with a dual diagnosis of depressive episodes and alcohol misuse experience more relationship breakdown and less social support. Additionally, on a social level these individuals experience difficulties in coping in the workplace, as well as having problems with financial management. It is recommended that the multidisciplinary team participate in the development of psycho-educational groups that focus on the education of dual diagnosis patients regarding their needs on each level of functioning. Furthermore, it is recommended that effective clinical communication patterns are in place to prevent fragmented service delivery to individuals with a dual diagnosis. It is recommended that service delivery takes place in all forms of service delivery, including individual therapy, psycho-educational groups, group work activities, as well as family counselling. Further research could focus on the following: 1) Extending the research population to areas outside the Gauteng Province, or even South Africa, in order to determine if these findings can be generalised to all patients with a dual diagnosis of depressive episodes and alcohol misuse; 2) Conducting the research in public health care centres to determine if the findings of this study are also prevalent in lower socio-economic classes (taking into consideration that the present study was conducted at a private psychiatric clinic); 3) Repeating the study with different combinations of psychiatric illnesses, as well as substances of abuse, to determine if the conclusions drawn from this study can be made applicable to dual diagnosis in general, or only to dual diagnosis with depressive episodes and alcohol misuse in particular.
Dissertation (MSW)--University of Pretoria, 2014.
tm2015
Social Work and Criminology
MSW
Unrestricted

In recent years there has been a significant increase in the number of people with a 'learning disability' also receiving a diagnosis of 'mental illness'. This shift in practice, heralded as scientific progress, has not been placed under close scrutiny. The aim of the current study was to explore the impact of this recent extension of medicalised accounts on people with a 'learning disability'. A discursive psychological approach was adopted to examine how seven people with a dual diagnosis negotiated and managed their ascribed identities during interviews. The initial research questions focused on the implications of subtle operations of power for individuals with a dual diagnosis, however on examination of the data it became apparent that this phenomenon was clearly evident in the research interviews conducted for the present study. The focus of the analysis was then directed at the sequential and procedural structure of the interviews, as an illustration of how they may be understood as an artefact of asymmetrical social roles and identities. This shift allowed for a greater focus on how the participants constructed their relationships with professionals, using their interaction with the interviewer as psychologist as an exemplar. The results provide further support for findings that individuals cast as questionable utilise strategies for accounting that indicate that they are vastly more 'competent' and 'rational' than they are credited for by the 'psy'-complex. The participants' construction and negotiation of their membership to social categories demonstrates that their identities are not fixed, but instead are occasioned and contestable, and dependent on the local institutional context. A further feature of the analysis highlights the politics that surrounds talk, displayed by the participants' construction of talk with a psychologist as 'helpful', as opposed to other forms of talk, such as talk that serves to challenge, as'unhelpful'. The findings call into question the probity of applying a conceptual framework that locates assumed pathology in individuals already deemed to be wholly impaired. Furthermore, the study highlights the necessity for psychologists, policy makers and researchers to investigate the interactional nature of so called 'impairment', and to explore their roles in creating and perpetuating oppressive practices. Potential avenues for further action are discussed

This study explores the dual diagnosis substance abuse phenomenon within the context of Vancouver area mental health boarding homes. The target population consisted of thirty-nine mental health boarding homes used by Greater Vancouver Mental Health Services, Mental Health Residental Services. An attempt was made to survey directors (n=37), staff (n=unknown), and residents (n = 422), to: estimate the prevalence of dual diagnosis substance abuse within these homes; look for associations between substance use/abuse and the demographic characteristics of staff, directors, and residents; examine boarding home policies; and to establish what, if any, services should be developed. Questionnaires were completed by twenty-nine directors (78%), twenty staff members (% unknown), and ten residents (3%), from twenty-nine boarding homes with a total resident population of 358. Results indicated that one hundred and fifteen residents (32%) consumed alcohol, and 57 residents (16%) had consumed alcohol during a specified two week period. Only eight residents (2%) out of a potential 358 (from four different facilities) reportedly had substance related problems during the specified two week period. However, substance abuse was identified in eleven facilities (38%), without referrence to the two week time limitation. Further, staff and directors from fifteen facilities (52%) had at some time tried to get help for a resident with a substance abuse problem. Thus, while very few residents reportedly had dual diagnosis substance abuse problems, a considerably greater number of boarding homes reportedly had problems related to dual diagnosis substance abuse. Twenty-four directors (86%) and thirteen staff (68%) were interested in receiving a workshop on dual diagnosis substance abuse. It is the recommendation of this author that a drug education program/workshop for boarding home directors and staff be developed through the Greater Vancouver Mental Health Services "dual diagnosis program."
Arts, Faculty of
Social Work, School of
Graduate

The purpose of this study was to examine the prevalence of the comorbidity of emotional/behavioral disorders (EBD) and speech/language disorders among those students identified as under The Individuals With Disabilities Education Act criteria as emotionally disturbed and speech impaired. The literature reviewed included clinical and school settings that examined a cooccurrence of language disorders in the EBD population. Other research reported a lack of routine involvement of speech/language therapists in the assessment of the EBD population. Implications from clinical studies suggested a need for greater attention to language disorders in a multi- and interdisciplinary assessment. This study investigated the prevalence of the dual occurrence of EBD and speech/language disorders in Grades 2 through 6 in Texas schools in light of the known research. Relationships in ethnicity and socioeconomic status were examined using chi-square test of independence. Aggregate data were obtained from the database of the Texas Pupil Information Management System and from survey questionnaire responses provided by speech therapists in selected districts. The literature review focused on the impact of language in the development of appropriate personal interactions and communication skills, especially those relevant to pragmatic language factors and the implications of language competency in successful personal living and career roles and supported the importance of language as an important contributor to a person's life success and the correlation of EBD disabilities and speech/language disorders. Social skills instruction, the relationship of language, especially pragmatics, and social competencies for this population are included. The results revealed a relationship between ethnicity and speech/language disorders among the students identified with EBD. In considering the population of students identified as EBD and language disordered, a significant relationship was found between ethnicity and socioeconomic status. Recommendations include suggestions for future research, assessment procedures, classroom interventions, and data collection methods.

The relationship between alcoholism and generalized anxiety disorder (GAD) has been discussed in two research areas: research on the prevalence of GAD in alcoholics, and the prevalence of alcoholism in individuals diagnosed with GAD. Studies indicate that between 6 to 26% of alcoholics have a current diagnosis of GAD, with a lifetime prevalence rate of up 51%. In the general population, 4% would currently receive a diagnosis of GAD, with a lifetime prevalence of 8%. This meta-analytic review of the empirical literature examines the relationship between GAD and alcoholism. The author used percentages to compare the results of various studies. The averaged results of these various studies suggested there is a 25% comorbidity rate of GAD and alcoholism. critical review of the studies examined in this review revealed substantial methodological errors. Based on a critical review of the research methodology in the studies cited, the author proposed further research.

The goal of the study was to explore how adults living with stimulant abuse and bipolar disorder experience treatment at treatment centres in the Gauteng Province. As the study was aimed at gaining an in-depth understanding of the lived experiences of service users in terms of treatment, a qualitative research approach was implemented. The research findings were aimed at adding knowledge to the field of social work, which could contribute to the development of treatment programmes and possible policy changes that could positively impact the recovery of individuals living with a dual-diagnosis, specifically the dual-diagnosis of bipolar disorder and stimulant abuse. A phenomenological research design was used as it allowed the researcher to discover and report on the details pertaining to the participants' experiences in terms of the treatment they received. The phenomenological research design also enabled the researcher to describe the commonalities and discords expressed by participants in relation to the phenomenon. The sampling process for the research study took place in three phases. In the first phase, purposive sampling was implemented to select three substance abuse treatment centres in the Gauteng Province, and more specifically the Tshwane Metropolitan Municipality. The second phase of sampling was also purposive sampling, where inclusion criteria were supplied to a social worker at each treatment centre who identified possible participants. During the third phase of sampling, possible participants were approached and informed of the study and ultimately four (N=4) individuals volunteered to participate in the study. Data was collected through the use of semi-structured one-on-one interviews which were guided by an interview schedule. Data gathered during the literature review and interviews were analysed through the process of thematic analysis and aimed at answering the research question "How do adults living with stimulant abuse and bipolar disorder experience services at treatment centres in the Gauteng Province?" The key findings indicate that admission to in-patient treatment programmes, for both stimulant abuse and psychiatric care, was prevalent among all participants, but re-occurring admissions to substance abuse treatment was more evident. Stimulants were primarily used as a means of coping with moods and emotions, as unstable mood patterns and emotions persisted regardless of the pharmacological treatment for bipolar disorder. The most helpful component of treatment which aided participants in managing their mood was counselling. When stimulants were not available and counselling was insufficient, other means of achieving psychological relieve were employed by participants, such as exercise, nicotine use, sweets and caffeine. The role of religion and spirituality in treatment is not clear, but all participants believe that religion and spirituality should be included in treatment. The need for education in terms of bipolar disorder, addictive behaviours, lifestyle changes and coping mechanisms were mentioned by most participants. In addition to education provided by professionals, participants expressed a need for sharing experiences with individuals that have managed to recover from bipolar disorder and/or stimulant abuse. When treatment plans and goals are set participants believe that they and their family should be included, a factor relevant to in-patient and reintegration services. With regards to in-patient treatment programmes, the psychosocial-cultural environment created within the physical environment was also mentioned as a component that needs to be considered. In order to deliver services that allow for the effective treatment and reintegration of individuals that abuse stimulants and are diagnosed with bipolar disorder the following recommendations are made: 1) Interventions, including prevention and early interventions, should be developed based on research findings focused on dual-diagnosis, to ensure that concurrent treatment and reintegration is achieved and sustained, thus promoting recovery, or the management, of both disorders. 2) Education in terms of stimulant addiction, cross-addiction, bipolar disorder, lifestyle changes, coping skills, as well as the interplay between these factors should be included in treatment programmes, however, education should be expanded to service providers and extended to family members too. 3) The role of religion and spirituality as part of dual-diagnosis treatment should be considered. 4) Treatment and support groups that focus on the specific dual-diagnosis of stimulant use and bipolar disorder, should be developed as part of in-patient treatment programmes, as well as supporting out-patient programmes, which could improve long-term recovery. 5) The physical and the psychosocial environments which are conducive to the recovery of dual-diagnosis patients should be established, as these environments could possibly be replicated, for example at home, and could ensure long-term recovery. 6) Service users and their families should be included in decisions regarding treatment planning and reintegration, as inclusion in this area of treatment could promote compliance to treatment. However, it should be stated that many of these recommendations are dependent on governing bodies, such as the Department of Social Development and the Department of Health, who are responsible for changing, developing and monitoring policies guiding treatment, which has a direct impact on the long-term recovery of individuals living with this dual-diagnosis. Future research studies that can contribute to understanding this phenomenon can focus on 1) Repeating the study within other private and government based treatment centres across South Africa in order to determine whether treatment needs differ or whether it presents the same results. 2) Comparing studies from different centres and areas of South Africa in order to establish treatment needs of individuals diagnosed with a dual-diagnosis. 3) Research should be done to determine the actual prevalence of the dual-diagnosis of stimulant abuse and bipolar disorder in South Africa, focused on admissions in both substance abuse treatment centres and psychiatric treatment facilities. 4) Treatment programmes developed from research findings should be implemented, and research should be conducted on the effectiveness of treatment. 5) Research on different combinations of dual-diagnosis is necessary to determine how treatment needs differ, as this will ensure the development of appropriate treatment. Individuals working at treatment centres (for both substance abuse and psychiatric disorders) should be aware of the needs of dual-diagnosis patients, and be educated on this phenomenon. 6) It is recommended that research should be done with the staff of psychiatric treatment centres, as well as staff at substance abuse treatment centres, to determine their views and knowledge in terms of dual-diagnosis. 7) Research focussed on the costs of not treating dual-diagnosis should be conducted. When the actual costs of non-treatment are established, government agencies and the private sector might be more prone to support treatment strategies. 8) Intervention strategies focused on families of dual-diagnosis patients should be implemented and the impact of these interventions on both patients and families should be researched. 9) More research in terms of this dual-diagnosis is necessary as this could allow for the development of effective treatment strategies that could lower relapse and readmission rates.
Mini Dissertation (MSW)--University of Pretoria, 2017.
Social Work and Criminology
MSW
Unrestricted

Thesis (Ph. D)--Ohio State University, 2003.
Title from first page of PDF file. Document formatted into pages; contains xiii, 170 p.: ill. (some col.). Includes abstract and vita. Advisors: Bruce Growick and John Finch, College of Education. Includes bibliographical references (p. 160-170).

Thesis (Ph. D.)--Ohio State University, 2005.
Title from first page of PDF file. Document formatted into pages; contains xi, 135 p. Includes bibliographical references (p. 125-132). Available online via OhioLINK's ETD Center

TITLE: The Effects of Vocational Skills Training on the On-Task Participation of Individuals With a Dual Diagnosis MAJOR PROFESSOR: Brandon F. Greene, Ph.D The present study was conducted to determine the effects of vocational skills training on the on-task participation and comments made by individuals with dual diagnoses during treatment sessions. The study began with a Vocational Skills/Cleaning group (treatment phase) in which researchers tracked on-task and off-task comments made by group members during the first and last ten minutes of vocational skills training. For the remaining time, participants were presented with a cleaning activity and the degree of participation in the identified activity was recorded. Next, the researcher measured the on-task and off-task comments made during the Typical Group/Psycho Social Rehab (PSR) phase involving the usual group discussions that were the common habilitative approach at the facility. Results showed that both on-task comments and on-task participation increased and were maintained above the normative levels during vocational skills training. The study also assessed two specific target behaviors for one group member who engaged in elopement and door slamming at high rates during typical group sessions. Both elopement and door slamming decreased during the treatment phase of the intervention providing additional support for the use of vocational skills training in congregate settings for adults with dual diagnoses.

The purpose of this study was to examine the comorbidity of substance use disorders and mental illness: Addressing access to dual diagnosis treatment centers and the correlation of perceived effectiveness. The research project was conducted in collaboration with California State University, San Bernardino, (CSUSB) and the Master in Social Work Program. The study used a survey designed with items that measured the participant’s perception of availability and effectiveness of dual diagnosis treatment centers. A quantitative study was conducted using a fixed choice response and data was analyzed on an interval measurement scale. Frequencies and cross tabulations were used to present participant’s answers. 86.7% of respondents perceived that they benefited from a dual diagnosis treatment center. All respondents perceived they were better equipped to manage their alcoholism after treatment, were better equipped to manage their mental illness after treatment, and better equipped to be a contributing member of society after treatment. The findings of this research may contribute to social work's knowledge of treating comorbidity by providing insight into the factors that contribute to individual's effectiveness in regards to post dual diagnosis treatment.

Research in the field of dual diagnosis (the coexistence of symptoms indicative of a substance abuse problem and a mental health problem) has expanded immensely over the past 15 years. Unfortunately, much of the existing literature available on this topic is limited to adult populations. The researcher explored the rate of dual diagnosis in the adolescent population by conducting a secondary data analysis of the Canadian Incidence Study of Child Abuse and Neglect (CIS-2003; Trocme et al., 2005). The rate of having one or more substance abuse problems in the CIS-2003 was 8.8% and the rate of having one or more mental health problems was 23.6%. Dual diagnosis was found to be under-reported in the child welfare system in Canada. Results of the secondary data analysis indicate that 4.4% of the total sample of adolescents aged between 10 and 15 years old had symptoms indicative of a dual diagnosis over the 3 month study period (n=4381). By providing a profile of child and caregiver characteristics and risk factors associated with dual diagnosis, clinicians from all realms can become better equipped to understand these issues. In the future, Social Workers and other professionals can work collaboratively on identification of DD and improving outcomes for youth and families affected by symptoms of a dual diagnosis.

El Hospital Provincial de Castellón adaptó la Terapia Psicoeducativa Motivacional Breve (efectiva en pacientes con trastorno por uso de sustancias (TUS) en Unidad de Desintoxicación Hospitalaria) para pacientes con patología dual (PD)(TPMB-D). Este estudio experimental doble ciego usó dos grupos aleatorios para evaluar la eficacia de la TPMB-D comparada con terapia ocupacional (TO) en pacientes hospitalizados con TUS y con PD. Completaron el estudio 163 pacientes, de los que el 68.7% presentaban PD y el 31,3% TUS. Se evaluaron pre y postest su nivel de conocimientos sobre adicciones y PD (cuestionario ad hoc) y su motivación para el cambio (cuestionario SOCRATES 8D de Miller y Tonigan), y la satisfacción con la terapia recibida (Treatment Perceptions Questionnaire de Marsden et al.) se evaluó postest. La TPMB-D aumenta la motivación para el cambio y los conocimientos sobre adicciones y PD más que la TO, generando también niveles más altos de satisfacción.
The Provincial Hospital of Castellon has adapted Brief Motivational Psychoeducational Therapy (effective in substance use disorder (SUD) patients in the Hospital's Detoxification Unit) for Dual Diagnosis (DD) patients (D-BMPT). This double-blind experimental study used two randomized groups with the objective of assessing the efficacy of D-BMPT compared to occupational therapy (OT) in patients hospitalized with SUD and with DD. One hundred and sixty three patients completed the study, of which 68.7% presented with DD and 31.3% with SUD. Their level of knowledge about drug addictions and DD (ad hoc questionnaire) and their motivation for change (Miller and Tonigan's SOCRATES 8D questionnaire) were evaluated pre- and post-treatment, and their satisfaction with the therapy received (Marsden et al.'s Treatment Perceptions Questionnaire) was evaluated post-treatment. D-BMPT increases motivation for change and the knowledge about drug addictions and DD more than OT, also generates higher levels of satisfaction.