Download Support clients with a mental health and AOD diagnosis

Support clients with mental health and
AOD diagnosis
Mental illness and mental health
2
Predisposing factors of mental illness and substance use
disorders
7
Factors that influence the onset of mental illness and substance
abuse disorders
9
Signs and indicators of mental illness
10
Assessing a person with a dual diagnosis
18
Screening clients for a dual diagnosis condition
24
Impact of a dual diagnosis
31
The Mental Health Act
34
Summary
36
Additional resources
42
Glossary
43
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Mental illness and mental health
When you think of mental illness what do you think of? Ask five people in
your own family or social network what they consider mental illness to be
and you will probably get a range of responses.
So let’s see what people think of when they hear the words ‘mental illness’.
Activity 1: Mental illness
1
Ask five people you know what they understand or consider mental illness to be and
write down the responses here.
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2
Now that you have completed this task, which of the above responses is closest to
what you consider mental illness to be?
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3
Now put together a definition of what you consider mental illness to be.
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Feedback 1
You may have got a range of responses to this task, and that is
understandable. In any discussion of mental illness it is worth trying to
understand what mental health is, in order to better understand the context
of mental illness.
Mental illness may be defined as a set of behavioural or psychological
responses that interfere with or inhibit a person’s ability to comfortably or
effectively meet human needs and function within a society. The American
Psychiatric Association’s definition of mental illness or mental disorder is:
A clinically significant behavioural or psychological syndrome or pattern
that occurs in an individual and that is associated with present distress
(some sort of painful symptom) or disability (ie impairment in one or
more important areas of functioning) or with a significantly increased risk
of suffering death, pain, disability, or an important loss of freedom.
(APA, 1994)
It is estimated by the National Association of Mental Health that 40% of the
population will seek psychiatric treatment at some point in their lives. It is
also estimated that one in every five people will develop a diagnosable
mental illness. Few families in Australia will be untouched by mental
illness, be it mild to extreme.
Determining just how many people in our community have mental illness is
one of the purposes of the field of epidemiology. Epidemiology is the study
of patterns of disease in the population. Key terms used with this discipline
are:

incidence

prevalence.
Incidence refers to new cases of a condition that occurs during a specified
period of time, say the last twelve months. Prevalence refers to all cases of a
disease, both new and existing cases.
The estimate of people living with mental disorders (epidemiology) has
changed over time due to changes in the definitions and diagnosis of mental
health and mental illness. In the early 1950s the rates of mental illness
estimated by epidemiologists in the USA were far higher than today’s
estimates. When more restrictive definitions that reflected a more
contemporary view about mental illness were used, the rates of mental
disorders dropped. Instead of classifying anyone with signs and symptoms
as being mentally ill, more recent practice has been to identify people as
mentally ill if they have a cluster of signs and symptoms that, when
combined together, impairs a persons ability to function.
Research confirms that people with a mental illness are more likely to have
a substance use disorder than people who do not have a mental illness. It has
also been argued by researchers that people who have a substance use
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disorder are more likely to have a psychiatric illness. The relationship
between mental health disorders and substance use is quite complex. People
who have both a mental illness and a substance use disorder are all very
different from each other. They may present with a range of disorders that
may vary in severity and intensity.
Information collected from the National Survey of Mental Health and
Wellbeing of Adults in Australia confirmed that men and women have
similar rates of mental illness but the types of disorders differed. Men, for
example, are twice as likely to have a substance use disorder whereas
women have higher rates of anxiety.
A mental illness or mental disorder is more commonly understood as a
diagnosable illness that significantly interferes with a person’s cognitive,
emotional and social abilities. So, what then is mental health?
Activity 2: Mental health
1
When we use the term mental health what do we mean?
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2
Ask five people you know what they consider mental health to be and write down a
summary of their responses below.
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Feedback 2
You could argue that mental health is the opposite of mental illness but that
would be incorrect.
A definition of mental health from Australian Health Ministers (1992) is:
The capacity of individuals within groups and the environment to interact
with one another in ways that promote subjective wellbeing, optimal
development and the use of mental abilities (cognitive, affective and
relational) and achievement of individuals and collective goals consistent
with justice.
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There is no universally accepted definition for mental health. People who
work in the community services and health industry (CSHI) tend to agree
that mental health is a positive state in which a person is responsible,
displays self-awareness, is self-directive, is reasonably worry free and can
cope with day to day tensions. When a person is able to carry out their role
in society and their behaviour is appropriate to the environment, that person
will be referred to as being ‘mentally healthy’. It can be argued that an
individual who is mentally healthy can function comfortably within society,
is accepted within a group and generally satisfied with their achievements.
Mental health and mental illness are not polar opposites but need to be
thought of as points along a continuum.
Activity 3: A description of mental health
Now in your own words describe what you consider mental health to be.
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Feedback 3
So what is mental health?
It is a state of successful performance of mental function, resulting in
productive activities, fulfilling relationships with other people and the
ability to adapt to change and cope with adversity.
It is indispensable to personal wellbeing, family and interpersonal
relationships and to be able to contribute to the community or society.
It is the springboard of thinking and communications skills, learning,
emotional growth, resilience and self-esteem.
What it means to be mentally healthy is subject to many different
interpretations, and rooted in value judgements that may vary across
cultures.
So how does mental illness differ from mental health?
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As we have discussed above, mental illness is the term that refers
collectively to all diagnosable mental disorders. Mental disorders are health
conditions that are characterised by alterations in thinking, mood and
behaviour associated with distress and/or impaired functioning. Examples of
disorders that are characterised by alterations in thinking, mood and
behaviour are as follows:

A condition called Alzheimer’s disease (a type of senility) exemplifies a
mental disorder largely marked by alterations in thinking.

Depression exemplifies a mental disorder marked by alterations in
mood.

Attention deficit disorder (ADD) exemplifies a mental disorder largely
marked by alterations in behaviour (overactivity) and/or thinking
(inability to concentrate).
Alterations in thinking, mood and behaviour contributes to a host of
problems such as client distress, impaired ability to function and cope, or
heightened risk of death, pain, disability, or loss of freedom.
Concepts of mental health and mental illness are defined, to some extent,
according to the beliefs and values of the society in which the person lives.
When a person is able to carry out their role in society and/or their
behaviours are adaptive to the environment, we may agree that the person is
‘mentally healthy’. Such individuals may function comfortably within
society, may be accepted within a group and are generally satisfied with
their achievements. These last two sentences may sound somewhat
subjective and can be easily challenged. Next we’ll tease out some issues
that make the difference between mental health and mental illness a little
blurry.
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Predisposing factors of mental illness
and substance use disorders
Over the past 15 years researchers have identified increasing numbers of
people in our society who have and are developing comorbid (mental health
and substance use disorders, otherwise referred to as a dual diagnosis
condition). The question that often gets asked is: have these two conditions
always existed side by side and it has only been recently that the links have
been made, or have there been other changes and influences in society that
has impacted upon this growing concern?
Activity 4: The increase in dual diagnosis
What do you think may be some of the reasons why we are seeing more and more
people in our society with both mental health and substance use disorders?
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Feedback 4
Some of the reasons proposed to answer this question were put forward by
two researchers (Smith and Hucker) in the 1990s. Their study was focused
at the level of serious mental illness and highlighted that some of the
reasons why there has been an increase in substance use disorders in people
with psychiatric illness are as follows:

Many people are using substances to self-medicate away their
psychological pain.

Some of the side effects of the medication prescribed for mental illness
may cause people to self-medicate a range of legal and illegal drugs.

It may be a way to increase social interaction between people.

It may be a way of gaining acceptance and entry to certain subcultures.

It may be a way of coping with some of the disabilities of mental illness
such as poverty and isolation.
In addition to these points there are now more people with serious mental
illness living in the community compared to those who were once residing
in psychiatric institutions. This, in itself, exposes many people to substanceusing cultures. In addition, many researchers argue that there has been an
increase in social acceptability and use of substances, many of which
contribute to higher levels of mental health disorders.
Activity 5: Is dual diagnosis on the increase?
As a student it is important for you to try and tease out this question. Do you think that
the combination of mental illness and substance use disorders (dual diagnosis) is
increasing, or that we are just more aware of this problem, as a society? Give this
question some thought and write down your response here.
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Feedback 5
We do know that there has been a steady rise in the use of drugs in our
society. Australian statistics confirm that the proportion of young people
using cannabis, inhalants, hallucinogens and narcotics has increased over
the past 15 years.
Research undertaken by Rutter and Smith (1995) suggested that there is an
increasing trend of mental health disorders in young people. It is also
possible that due to a heightened level of interest and awareness of dual
diagnosis over the past 15 years that people who are treating mental illness
are now more aware of, and looking for, any evidence of this problem in
their clients/patients.
So the question does not have a clear answer. Many mental health clinicians
claim that dual diagnosis is to be anticipated when a person’s mental health
is out of balance for whatever reason. The difficulty is being able to tease
out whether the mental illness leads to the substance use disorder or the
substance use leads to the mental illness.
Factors that influence the onset of
mental illness and substance abuse
disorders
What are the reasons why people develop a mental illness/substance use
disorder? One way to look at this complex question is to examine the three
major factors that influence mental health. These factors are:
1
Biological factors
Biological factors include genetic predisposition; physical health;
neuroanatomy and physiology.
2
Psychological factors
Psychological factors include nurturing during childhood; parent, child
and sibling interactions; intelligence; self-concept; skills; talents;
creativity and emotional development.
3
Socio-cultural factors
Socio-cultural factors include family stability; child rearing patterns;
economic resources; housing; religious beliefs and values.
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Signs and indicators of mental illness
Activity 6: Mental health conditions
Brainstorm as many mental health conditions that you can think of that would indicate
mental illness. Start with some of the major conditions, for example: schizophrenia.
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Feedback 6
There are many diagnosable mental health conditions. One of the most
recognised guides to mental health conditions is the Diagnostic and
Statistical Manual of Mental Disorders (DSM).
You might have identified:

psychotic disorders

serious mental illness such as schizophrenia

organic disorders

anxiety disorders

mood disorders such as depression and bipolar disorder

substance abuse disorders

anxiety disorder such as post-traumatic stress disorder, panic disorder,
and phobias

personality disorders.
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Activity 7: Manifestations of mental illness
As identified in the last activity there are a number mental health disorders, but how do
they present? What are some of the more common signs and symptoms of mental illness?
List what you consider to be some of the signs and symptoms of mental illness.
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Feedback 7
People that experience any of the diagnosable mental health disorders may
present with a variety of symptoms that may include the following:

inappropriate or extreme anxiety

disturbances of thought and perception

altered mood states

change in thinking patterns or cognitive dysfunction.
Many of these symptoms may be specific to a particular diagnosis or
cultural influence. For example, the symptoms of psychosis, being
disturbances of thought and perception, are most commonly associated with
schizophrenia.
We have identified the broad range of symptoms associated with mental
illness. Now we are going to look at these symptoms in more detail.
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Activity 8: Anxiety
How would you explain what ‘anxiety’ is to a person from another culture who is
unfamiliar with this term?
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Feedback 8
Anxiety is one of the most readily accessible and easily understood of the
major symptoms of mental disorders. We all experience anxiety in many
forms throughout the course of performing various activities or participating
in events. It may often take the form of intense fear experienced in response
to an immediately threatening experience, such as narrowly avoiding a
traffic accident. Experiences such as this are typically accompanied by
strong emotional responses of fear and dread as well as physical signs of
anxiety such as rapid heart rate and perspiration.
Some of the more common symptoms of anxiety include:

feelings of fear or dread

trembling, restlessness and muscle tension

rapid heart rate (tachycardia)

light headedness or dizziness
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perspiration
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cold hands and feet

shortness of breath.
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Activity 9: Psychosis
When you hear the term ‘psychosis’ or someone is referred to as being ‘psychotic’
what do you think of?
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Feedback 9
Disturbances of perception and thought processes fall into a broad category
of symptoms referred to as psychosis. Psychosis is often described as being
out of touch with reality. Like anxiety, psychotic symptoms may occur in a
wide range of mental disorders. They are most characteristically associated
with the condition called schizophrenia, but psychotic symptoms can also
occur in severe mood disorders and in relation to excess use of drugs such as
amphetamines and cannabis. People who have a psychotic disorder may
experience a range of symptoms including hallucinations and delusions.
Activity 10: Hallucinations
If a person is said to be ‘hallucinating’ what do you understand by this term?
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Feedback 10
We all experience the world though the senses of hearing, smell, touch, taste
and sight. At times, people who experience hallucinations may experience
distortions of reality in the way they hear and see things that do not actually
exist in reality. An example might be someone who hears voices that no one
else can hear, or sees people or images that other people do not see.
Hallucinations are distortions of reality. The person who is experiencing an
hallucination has no awareness that the world is different for other people.
Cartoon of a
woman staring in the mirror and seeing psychedelic patterns swirling around her
head.
Activity 11: Delusions
What do you understand a ‘delusion’ to be? A delusion is one of the more common
symptoms of mental illness that may be seen in people with a serious mental illness and in
people who have been abusing psychoactive drugs such as amphetamines and cannabis for
prolonged periods of time.
In your own words define what you understand a delusion to be.
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Feedback 11
You may often hear in conversation someone being called ‘delusional’ but
this may bear little relationship to the group of symptoms of a serious
mental illness resulting from disordered interpretation of information.
A delusion is a false belief that an individual believes to be true despite
evidence to the contrary. A common example is paranoia, whereby a person
may have delusional beliefs that they are being followed and are fearful that
they may be harmed.
Symptoms associated with psychotic mental illness
Some of the more common acute symptoms of a psychotic mental illness
such schizophrenia include:

hallucinations

delusions

disorganised thought and behaviours

illogical thoughts

concrete thoughts

inability to experience pleasure

poor motivation and initiative.
Activity 12: Disturbances in mood
Most of us have a fairly good understanding of what is meant by ‘mood’. If someone says
to you that you are in a bad mood, we can acknowledge that we might not be feeling very
happy.
When you think about a disturbance of mood, what do think of?
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Feedback 12
Being happy or sad, elated or flat is sometimes quite difficult to describe or
put into clear words. The expression of mood may also have many cultural
differences. Some cultures may not show overt expressions of happiness and
sadness. Disturbances of mood are often seen and experienced as a sustained
feeling of sadness or sustained elevation of mood. As with anxiety and
psychosis, disturbances of mood may occur in a variety of different ways
attached to many different types of mental disorders.
The disorder most commonly associated with persistent sadness is major
depression, while the condition associated with sustained elevation or
fluctuation of mood is bipolar disorder (where the person may experience
both mania and depression at different times).
Symptoms associated with depression

persistent sadness or despair

insomnia (inability to sleep)

decreased appetite
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all physical motor functions slowed down

an inability to experience pleasure naturally

irritability
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apathy, poor motivation and social withdrawal
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hopelessness
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poor self-esteem

suicidal thoughts and possibly actions
Symptoms associated with mania

persistently elevated or euphoric mood

inappropriately high self-esteem (grandiosity)

decreased sleep

physical agitation

racing thoughts and distractibility

poor judgement and poor impulse control

rapid or pressured speech.
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Activity 13: Disturbances of thinking or cognition
Can you think of some conditions and behaviours that may impact upon our ability to
think clearly?
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Feedback 13
Cognitive function refers to the general ability to organise, process and
recall information. There are many functions commonly associated with
cognition such as the ability to execute complex sequences of tasks.
Disturbances of thinking or cognitive function may be seen in a number of
disorders:

Progressive deterioration of cognitive function is referred to as
dementia. Dementia may be caused by a number of specific conditions
including Alzheimer’s disease and Alcohol Related Brain Damage
(ARBD).

Impairment of cognitive function may also occur in other mental
disorders such as depression.

Changes in someone’s capacity to think and process information
frequently occurs as a result of a host of chemical, metabolic and
infectious diseases that can exert an influence on the brain.
The consequences of cognitive impairment can vary from short-term
memory loss to not being able to access longer-term memories. Attention,
concentration and higher intellectual functions can be impaired, as the
underlying disease process becomes worse. Language difficulties range
from having problems finding words to complete inability to comprehend or
use language altogether.
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Assessing a person with a dual
diagnosis
In this section we are going to look at some of the more common mental
illness presentations and how to recognise them. When we talk of dual
diagnosis (for example, having a person present with depression and heavy
drinking) it is often difficult to know what comes first. Is it the depression
that has led the person to heavy drinking? Or is it that, due to drinking too
much, problems have arisen such as getting fired from their job, relationship
breakdown and so on, and so the person has become depressed?
At times the picture may be unclear and confusing. An example might be a
young man with schizophrenia who smokes a lot of dope and re-experiences
psychotic symptoms. This is an example of a drug-induced psychosis.
Another example might be an alcoholic who drinks because she feels
depressed and shows signs of delirium when withdrawing from this drug.
The challenge is not only developing an awareness of the relationship
between mental illness and substance use disorders but to try and tease out
the relationships between the two.
Prevalence studies estimate that that between 30% and 80% of clients in
community and institutional treatment settings have coexisting mental
health and substance use disorders. Many studies, including one conducted
in the USA by Robins and Regier (1991), found that almost a third of people
who had a mental health disorder had experienced a substance use disorder
at some point. Studies also confirmed that a third of people with an alcohol
disorder had experienced a mental health disorder.
The Australian National Survey of Mental Health and Wellbeing (1998)
reported that approximately half of females and a quarter of males with a
substance use disorder met the criteria for a mental health disorder.
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Activity 14: Substance use disorder
What do you understand the condition ‘substance use disorder’ to be? In your own
words try and tease out a definition.
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Feedback 14
One way to describe this disorder is to look at the interrelationship of factors
associated with problematic substance use.
This model contains three components:
Diagram of
three overlapping circles and each circle is labelled: problems of intoxication;
problems of regular use; and problems of dependence.
These three components can exist as distinct entities but can also
interconnect to further compound the outcomes associated with substance
use.
In Australia, The Diagnostic and Statistical Manual of Mental Disorders
(DSM) is the classification system used within the Drug and Alcohol and
Mental Health areas. There are three components inclusive of substance
intoxication, substance misuse and substance dependence, as follows, that
are described by this classification system:
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1
The criterion for substance intoxication is defined as the development
of a reversible substance-specific syndrome due to recent ingestion of
(or exposure to) a substance.
2
The criterion for substance misuse is defined as a maladaptive pattern
of substance use leading to a clinically significant impairment or
distress, as manifested by one (or more) of the following, occurring
within a 12-month period:

recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home

recurrent substance use in situations in which it is physically
hazardous

recurrent substance use leading to legal problems (eg arrests for
substance-related disorderly conduct)

3
continued substance use due to having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of
the substance (eg arguments with the spouse about consequences of
intoxication, or physical fights).
The criterion for substance dependence is a maladaptive pattern of
substance use, leading to clinically significant impairment or distress, as
manifested by three (or more) of the following, occurring at any time in
the same 12-month period:

Tolerance, as defined by either of the following
– a need for markedly increased amounts of the substance to
achieve intoxication or the desired effect
– markedly diminished effect with continued use of the same
amount of the drug.

Withdrawal, as manifested by either of the following
– the characteristic withdrawal syndrome for the substance
– the same (or closely related) substance is taken to relieve or
avoid a withdrawal syndrome
– the substance is often taken in larger amounts or over longer
periods of time than was intended
– there is a persistent desire or unsuccessful efforts to cut down
or control substance use
– a great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
– important social, occupational or recreational activities are
given up or reduced because of substance use
– the substance use is continued despite the knowledge of having
a persistent or recurrent physical or psychological problem that
is likely to have been caused or made worse by the substance.
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Activity 15: Drug-induced psychosis
There are a number of drugs that, when used to excess, may bring on symptoms of a
psychotic illness. In the space below identify some of the more common drugs that
may lead the user to experience a psychosis.
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Feedback 15
Drugs that may cause or bring on psychosis include substances from the
stimulant drug group. These include methamphetamine, ‘ice’ and other
psycho-stimulants. Marijuana, when used excessively, is another drug that
has the effect of bringing on psychotic symptoms. It is also worth
mentioning that some people, when withdrawing from alcohol, may
experience hallucinations and delusions—key symptoms of psychosis.
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Activity 16: Issues to consider in dual diagnosis
What are some of the broad areas that come to mind in terms of assessing a client who you
suspect may have mental illness and substance use disorders? What sorts of things would
you be looking at? Eg cognitive functions, anxiety …
Complete this mind map.
Mind map with the words dual diagnosis in the centre.
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Feedback 16
When looking for or assessing a person for a dual diagnosis there are many
different symptoms and behaviours that can be identified.
A completed mind map that shows the following symptoms of behaviours
associated with dual diagnosis: anxiety, behaviour change, delirium, withdrawal
from drugs, cognitive functions, hallucinations, substance use patterns,
deppession, delusions, psychosis.
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Screening clients for a dual diagnosis
condition
How would you go about assessing a client who you suspected of having a
dual diagnosis? What questions would you ask them? What would you be
looking for in terms of their presenting signs and symptoms? This is a
difficult task as it does require teasing out issues like whether the client has
a psychotic disorder, or has an organic disorder (described later), anxiety
disorder or depressive disorder.
Let’s look at the screening process that may tease out the issues specific to
clients with psychotic disorders.
Clients with psychotic disorders
The term psychosis is used to refer to a range of psychiatric conditions
where there has been some loss of contact with reality. Some points to note:

Psychosis has many causes and can be associated with a number of
conditions including schizophrenia, bipolar affective disorder, delirium,
drug intoxication or drug withdrawal, major depression or head injury.

Psychosis is not an uncommon condition, and is most likely to occur in
young adults.

Many people who experience a psychotic illness make a full recovery.
Presenting clients
Clients with psychotic symptoms may present with:

an acute onset of psychotic symptoms, that is, the symptoms occur very
quickly over a short period of time

a reoccurrence of an existing psychotic illness such as schizophrenia

side-effects of medication

problems associated with the abuse of alcohol or other drugs

a depressed mood or a background of psychotic illness.
Symptoms of psychosis
Some of the symptoms of psychosis include:

Disorganised thinking—an inability to concentrate, to remember and to
be able to follow a conversation. Sentences are unclear and make very
little sense. The thinking of a person with a psychotic illness is difficult
and clients may have blocked thoughts, or their thoughts are too fast or
too slow, or may not be linked together appropriately.
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
Delusions may be present which are fixed, false beliefs that cannot be
challenged by logical argument or by reasoning with the person.

Hallucinations may also be present. These are false perceptions which
occur in the absence of any external stimuli. All the senses may be
involved but most often hallucinations are auditory with the client
stating that they hear voices in their head.

Changed feelings include changes in mood that may be seen as flat,
extreme or inappropriate emotions.

Changes in behaviour inclusive of inappropriate, disorganised or bizarre
actions.
Activity 17: Screening of clients who may have a
psychotic illness
In trying to identify features of psychosis, what would you look for?
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Feedback 17
A person with a psychotic disorder may have the following features:
Appearance:
They may look perplexed, angry, dishevelled, have poor personal hygiene,
and be dressed inappropriately or in a bizarre manner.
Behaviour:
Their behaviour maybe agitated, restless, inappropriate or strange; staring at
one place in a room, head turning or gesturing in the absence of any stimuli,
the eyes following something that is not observable to other people;
mumbling or conversing with unseen person(s).
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Verbal cues:
Such a person may have difficulties in following or responding to questions;
the responses of the person may make no sense or the person may give too
much information that is irrelevant or provide no information at all.
Clients who may have an organic brain disorder
Activity 18: Identifying clients who may have an
organic brain disorder
An organic brain disorder is a mental disorder in which intellectual or emotional
functioning, or both, are impaired due to some sort of pathology (disease or disorder) or
dysfunction of the brain. An example of an organic disorder is delirium.
In trying to identify features of an organic brain disorder in a client, what would you
look for?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Feedback 18
A person with an organic brain disorder (specifically delirium) may have the
following features:
Delirium:
This disorder is a collection of signs and symptoms indicative of Acute
Brain Failure. There are many causes of delirium, though the symptoms are
similar and characterised by alteration in the client’s level of consciousness,
and there are significant alterations in the way the person thinks, judges,
reasons, and plans.
It usually has a sudden onset with a brief and fluctuating course and may
improve rapidly when the causative factor is identified and eliminated.
It is a common disorder in the elderly and in people with Alzheimer’s.
There are many causes of delirium including drug intoxication and
withdrawal (from alcohol and prescribed medications), metabolic and
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nutritional imbalances, infections and fevers, neurological disorders such as
brain tumours, and even the stress of a change in the person’s surroundings
can trigger delirium.
Symptoms of delirium
Some of the features of delirium include:

disturbance of cognition (in the way a person thinks, judges, reasons,
and plans). There may be some level of change with regard to the level
of consciousness, attention and recent memory

delusions may be present

perceptual distortions and hallucinations may be present

disturbances in activity seen as over or under-activity

disturbance of sleep and a worsening of symptoms at night

emotional disturbances including anxiety, fear, irritability and
depression may be present.
Screening of clients who may have delirium
A person with delirium may have the following features:
Appearance:
The client may look perplexed, apprehensive or fearful, dishevelled or
unkempt, inappropriately dressed and may have signs of a physical illness.
Behaviour:
They may be agitated, restless, extremely slow and inactive, repetitive
purposeless movements, gait disturbance (leans to one side when walking or
sitting); appear to respond to auditory hallucinations or to be observing
unseen objects or people or picking at unseen things on clothes or the skin.
Verbal cues:
A person with delirium may have difficulty in speaking or following
questions. Answers may not make sense and clients often respond in a
repetitive manner.
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Activity 19: What sort of things could you ask a
person with delirium?
In trying to gauge the extent of the condition, what questions would you consider
asking the client?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Feedback 19
It may be difficult to ask a person with delirium any questions, though
depending upon the severity of their delirium the following are appropriate:

How are you feeling at the moment?

What are the times that you feel at your worse?

Are your thoughts all mixed up?

How long have you felt like this?

Can you tell me the day, date and month?

Have you felt that people are against you or trying to harm you?

Have you had any strange experiences?

Have you had any problems with your physical health?

Do you see, hear, smell or feel things that you believe other people do
not?
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Screening of clients who may have an anxiety disorder
Anxiety is an uncomfortable feeling of apprehension and, in small doses, is
not uncommon. It is when anxiety starts to affect daily living that an anxiety
disorder is said to be present.
The symptoms of anxiety include:

restlessness and agitation

muscle tension, aches and pains

fast and rapid heart rate with occasional palpitations

sweating and dry mouth

dizziness and headaches

irritability and sleep disturbances

difficulty in concentrating

feelings of fearfulness

inability to cope.
People with anxiety may experience both physical and psychological
symptoms. Organic brain conditions and drug and alcohol misuse (taking
and withdrawing off some substances) are also associated with the
development of symptoms of anxiety.
Clients presenting
An anxious person may present with:

Panic symptoms that are characterised by shortness of breath, overbreathing (hyperventilating), palpitations, chest tightness, lightheadedness, tremors, sweating, nausea, tingling in the hands and feet,
and fear that the person is having a heart attack.

There may be physical symptoms such as a headache, upset stomach,
dizziness and fatigue.

Symptoms of both depression and anxiety may coexist.

Thoughts of suicide and self-harm may be present.
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Clients who may have a depressive disorder
Cartoon of a woman looking sad and alone.
Activity 20: Symptoms of depression
In trying to identify some of the symptoms of depression, what would you look for?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Feedback 20
Depression is a very common mental illness and may be seen in people with
a physical illness, chronic pain, disability, psychological distress and people
who use and abuse drugs.
There are quite a few symptoms of depression that include:

a low mood

a change in appetite and weight—some people do not feel hungry while
others eat more and put on weight

there may be a loss of experiencing pleasurable things

a loss of energy and motivation to do things

poor concentration and recent memory

sleep disturbances—difficulty getting off to sleep and frequent waking

agitation or feeling really slowed down

feelings of guilt, hopelessness and worthlessness

suicidal ideas may be present

physical aches and pains.
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Impact of a dual diagnosis
Activity 21: Peter
Consider the following scenario.
Peter is a 24 year-old man who has had a long history of depression and
substance abuse. He consumes large quantities of alcohol on a daily basis
and experiences the following symptoms of depression:

a very low mood most of the time

no appetite

poorly motivated to do things

poor concentration

experiences severe sleep disturbances

feels agitated most of the time

has marked feelings of guilt and hopelessness.
How do you think this combination of depression and a substance abuse disorder may
impact on the life of this person?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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Feedback 21
It is likely that Peter has quite a chaotic life. Did you consider the difficulty
for him to be able to maintain permanent and stable employment, a healthy
relationship, financial stability, his ability to undertake study, and so on?
There may also be social issues and health-related issues. The abuse of
alcohol may make Peter feel less depressed, though he may be consuming
so much alcohol that if he stops he may go into a physical withdrawal.
It is difficult to gauge what the impact of these two disorders must be like
for Peter. We can try and put ourselves in the shoes of someone like Peter
and ask what it may be like.
What about the impact of this dual diagnosis condition on family and
friends? Every corner of Peter’s life will be impacted upon by depression
and alcohol abuse whilst the two conditions remain acute and untreated.
Activity 22: Sandra
Consider the following scenario.
Sandra is a single mother of two young children. Since the age of 21 she
has been in and out of the local psychiatric unit on about four occasions
due to experiencing psychotic symptoms associated with schizophrenia.
Most of the time Sandra is symptom-free when she takes her medication
and stays away from smoking marijuana. She finds it a battle just to do
some of the basic day to day tasks, so she uses marijuana as a sort of ‘pick
me up’. She is aware of the risks of smoking dope in terms of her mental
illness becoming more pronounced, but she says that she wants to
‘experience pleasure and zone out for a while.’ Sandra is an accountant
who works part-time as her two children are not yet at school. Her mother
lives close and helps out with the children.
What do you think the impact of the abuse of marijuana and Sandra’s schizophrenic
illness might be on her life?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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Feedback 22
It appears that the use of marijuana combined with Sandra’s mental illness
has some devastating consequences. Let’s not look at how to fix the
situation but reflect upon the overall impact of not only the schizophrenic
illness but also the substance use disorder.
The impact is quite significant. Not only does Sandra become quite ill,
experiencing a range of psychotic symptoms, but her capacity to care for her
children and undertake work are seriously compromised. Income that is vital
to financial independence is in jeopardy. The relationship with her children
is disturbed, as is her capacity to care for them without some sort of external
assistance or supervision.
Legal problems might also cloud the picture, be they behaviours that Sandra
engages in when she is unwell, to loosing her capacity to voluntarily accept
treatment for a psychotic condition. She may find herself admitted to a
psychiatric unit and placed under the control of the Mental Health Act.
The impact of a dual diagnosis for a person such as Sandra is quite
devastating. Her whole world will be impacted upon and it is unlikely that
any corner is left untouched.
Apart from the short-term physical, social, emotional and spiritual impact of
a dual diagnosis, there is the longer-term scars of the illness. It may be that
people close to Sandra treat her differently and are always on the lookout for
signs of her illness.
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The Mental Health Act
The Mental Health Act is a law that governs the care and treatment of
people in NSW who experience a mental illness or mental disorder. (Mental
Health Act Guide Book, NSW Institute of Psychiatry, 1998).
The underlying philosophy of the Act is to ensure the best possible
treatment and care for people with a mental illness. The Mental Health Act
states that those who are mentally ill or disordered are to receive the best
possible care and treatment in the least restrictive environment, so that any
restriction on their liberty or interference with their rights, dignity and selfrespect is kept to a minimum.
The Mental Health Act provides a number of ways that allow a person to be
transported to a hospital for psychiatric assessment, where that person is not
capable or refuses to give consent. The use of the Mental Health Act does
not automatically imply that the person will be admitted to an inpatient
psychiatric unit. It includes Section 21 and Section 22 that make up
Schedule 2 and Section 24.
Schedule 2
Schedule 2 is made up of two parts (Sections 21 and 22). It involves an
assessment by a medical practitioner (Part 1, Section 21) and police
assistance to transport the person to an appropriate facility (Part 2, Section
22).
Section 21
A person may be taken and detained in a hospital when he/she has been
assessed by the medical practitioner who has formed the opinion that the
person is either ‘mentally ill’ or ‘mentally disordered’ and cannot be treated
or cared for outside of an inpatient psychiatric facility.
Section 22
A medical practitioner who has completed a Schedule 2 under Section 21
may request the assistance of the police in taking the person to hospital.
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Section 24
This gives the police broad power to take a person who appears to be
mentally disturbed to a hospital for assessment.
The police do not need a warrant and may apprehend the person in any
place, either public or private.
The police are required under the Act to wait until the person has been
assessed.
There will be occasions where someone with a dual diagnosis may be
forcibly apprehended against their will and taken to a hospital for
assessment. The impact of being taken against one’s wishes may be quite
devastating for the individual, family and friends but the outcome of not
having the legal authority of the Mental Health Act would be potentially
catastrophic.
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Summary
From the outset of this topic it was important that we acknowledged that a
substance use disorder and mental illness are both diseases. We considered
that people who experience a dual diagnosis are ill and do not have the
capacity to click their fingers and stop being psychotic or stop abusing drugs
without some significant input from, in the most part, health professionals.
You explored your understanding of mental illness and mental health.
Highlighted was the fact that mental health and mental illness mean
different things to different people. Mental illness conditions were described
and examined from anxiety disorders and depression to schizophrenia.
We explored the question of why some people develop a mental illness and
a substance use disorder. In doing so we looked at some of the signs and
indicators of mental illness in our society and some of the more common
symptoms and behaviours that may be experienced or observed.
Identification and assessment of a person with a dual diagnosis is a skill that
community services and health industry (CSHI) workers need to master. We
also looked at some of the presenting symptoms and behaviours that might
feature when assessing for dual diagnosis.
Lastly, we looked at the impact that dual diagnosis has on the lives of
people living with these illnesses. Working through some scenarios it
becomes clear that it is difficult for an observer to fully comprehend and
understand the impact a mental illness and a substance use disorder has on
the lives of people trapped with this combined illness.
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Check your progress
1
What do you understand to be the similarities and differences between mental health
and mental illness?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2
Here are two clients with mental health problems:
Paul has been living with a mental illness for the past 10 years. He has
been in and out of hospitals and it has only been in the past year that he
has been able to get back to work and be in a stable relationship.
Tom is experiencing quite a serious bout of depression following the
breakdown of his marriage.
In terms of mental health, who may be less ill?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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3
Identify some of the reasons why people may develop a mental illness and substance
use disorder.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4
Identify some of the more common signs and indicators of psychosis.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5
Identify some of the more common signs and indicators of depression.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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6
If you suspected that a client has an anxiety disorder and substance use disorder, what
would you be looking for?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Feedback: Check your progress
1
Mental health is:
a state of successful performance of mental function, resulting in
productive activities, fulfilling relationships with other people and the
ability to adapt to change and cope with adversity.
It is indispensable to personal wellbeing, family and interpersonal
relationships and being able to contribute to community or society.
It is the springboard of thinking and communications skills, learning,
emotional growth, resilience and self-esteem.
What it means to be mentally healthy is subject to many different
interpretations that are rooted in value judgements that may vary across
cultures.
Mental illness is:
the term that refers collectively to all diagnosable mental disorders.
Mental disorders are health conditions that are characterised by
alterations in thinking, mood and behaviour associated with distress
and/or impaired functioning. Examples of disorders that are
characterised by alterations in thinking, mood and behaviour are as
follows:

A condition called Alzheimer’s disease (a type of senility) that
exemplifies a mental disorder largely marked by alterations in
mood, especially thinking.

Depression exemplifies a mental disorder marked by alterations in
mood.

Attention deficit disorder (ADD) exemplifies a mental disorder
largely marked by alterations in behaviour (overactivity) and/or
thinking (inability to concentrate).
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Alterations in thinking, mood and behaviour contribute to a host of
problems such as client distress, impaired ability to function and cope,
or heightened risk of death, pain, disability, or loss of freedom.
2
This question is quite difficult to answer. Concepts of mental health and
mental illness are defined, to some extent, according to the beliefs and
values of the society within which the person lives in. When a person is
able to carry out his or her role in society and/or his or her behaviours
are adaptive to the environment, we may say that the person is
‘mentally healthy’. Such individuals may function comfortably within
society, may be accepted within a group and are generally satisfied with
their achievements.
3
There are three major factors that influence why some people may
develop a mental illness and substance use disorder.
Biological factors:
Biological factors include genetic predisposition; physical health;
neuroanatomy and physiology.
Psychological factors:
Psychological factors include nurturing during childhood; parent, child
and sibling interactions; intelligence; self-concept; skills; talents;
creativity and emotional development.
Socio-cultural factors:
Socio-cultural factors include family stability; child rearing patterns;
economic resources; housing; religious beliefs and values.
4
5
Some of the signs and symptoms of a person with a psychotic illness
may include the presence of:

hallucinations

delusions

disorganised thought and behaviours

illogical thoughts

concrete thoughts

inability to experience pleasure

poor motivation and initiative.
Some of the common signs and symptoms of depression include:

persistent sadness or despair

insomnia (inability to sleep)

decreased appetite

all physical motor functions slowed down

an inability to experience pleasure naturally

irritability

apathy, poor motivation and social withdrawal
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6

hopelessness

poor self esteem

suicidal thoughts and possibly actions.
The types of questions that may help to tease out an anxiety disorder
and substance use disorder are:

Do you feel restless and agitated?

Have you any muscle tension, aches and pains?

Do you experience a rapid heart rate?

Do you experience sweating, a dry mouth, dizziness and
headaches?

Do you suffer from irritability and sleep disturbances, difficulty in
concentrating and feelings of fearfulness?

Are you concerned about your ability to cope?

Are you using alcohol or other drugs and, if so, what are you using
and how often?
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Additional resources
Books
American Psychiatric Association (1994) Diagnostic and Statistical Manual
of Mental Disorders (4th edn), (DSM1V), Washington DC
Australian Health Ministers (1992) National Mental Health Plan Australian
Government Printing Service, Canberra
Hall W, Teesson M, Lynskey M, and Degenhardt L (1998) ‘The prevalance
in the past year of substance use and ICD-10 substance use disorders in
Australian adults; Findings from the Australian National Survey of Mental
Health and Wellbeing’ Technical Report No.63, National Drug and Alcohol
Research Centre
Mental Health Act Guide Book (1998) NSW Institute of Psychiatry
‘National Survey of Mental Health and Wellbeing of Adults in Australia’
(1997) Australian Bureau of Statistics
Robins L and Reiger D (eds) (1991) Psychiatric Disorders in America: The
Epidemiology Catchment Area Study New York, Free Press
Smith J and Hucker S (1994) ‘Schizophrenia and Substance Abuse’ British
Journal of Psychiatry 165
Videos
Drug Use and Misuse (1998) Lidnja Davis
What’s Your Poison (1999) Geoffrey Burchfield
Using the Internet
Australian Drug Foundation (ADF): www.adf.org.au
Alcohol and Drug Foundation: www.adfq.org
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Glossary
Affect
a subjective feeling or emotional tone often accompanied by bodily
expressions noticeable to others
Anxiety
an unpleasant feeling of fear and apprehension accompanied by increased
physical symptom arousal
Delirium
a state of great mental confusion in which consciousness is clouded,
attention cannot be sustained, and the stream of thought and speech is
incoherent; the person is probably disoriented, emotionally erratic, restless
or lethargic, and often has illusions, delusions, and hallucinations
Delusion
a fixed, false belief that a person is experiencing and believes to be real; a
person cannot be talked out of their delusional belief
Depression
an emotional state marked by great sadness and apprehension; feelings of
worthlessness and guilt; withdrawal from others; loss of sleep, appetite, and
sexual desire, or interest and pleasure in usual activities; and either lethargy
or agitation
Hallucination
a sensory perception that has the compelling sense of reality but that occurs
without any external stimulation; most commonly involves the hearing of
voices; other less common experiences can include seeing, feeling, tasting,
or smelling things which, to the person are real, but are not actually there
Schizophrenia
a group of psychotic disorders characterised by major disturbances in
thought, emotion and behaviour; disordered thinking in which ideas are not
logically related; faulty perception and attention; bizarre disturbances in
motor activity; flat or inappropriate emotion; reduced tolerance to stress of
interpersonal relations
Tolerance
a reduced sensitivity to a drug by the body; as a result of regular and
repeated doses of the drug, the body becomes used to or tolerant to the drug,
thus higher doses are required for the person to experience the desired drug
effects
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