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Chapter 32Clients with a Dual
Diagnosis
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
According to a report published by Journal of
the American Medical Association, 37% of
persons who abuse alcohol and 53% of
persons who abuse drugs also have at least
one serious mental illness. Of all persons
diagnosed with a mental disorder, 29% abuse
either alcohol or drugs.
—Mental Health America, 2009
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chemical dependency is a serious public
health problem. For people with mental
illness, comorbid chemical dependency
can be a catastrophic life problem.
—Vaccaro, 1999
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Learning Objectives
After studying this chapter, you should be able to
• Discuss the term dual diagnosis
• Explain the acronyms: MICAA, MICA, and CAMI
• Differentiate the two main theories related to the
development of a dual diagnosis
• Recognize the defining characteristics of clients with a
dual diagnosis
• Articulate the barriers to effective treatment of a client
with a dual diagnosis
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Learning Objectives (cont.)
• Interpret the four categories that have been
developed to describe the dually diagnosed client
• Describe why it is difficult to assess a client with a
dual diagnosis
• Summarize the following phases of treatment for
clients with a dual diagnosis: acute stabilization,
engagement, prolonged stabilization, and
rehabilitation and recovery including continuum of
care
• Explain why evaluation of a dually diagnosed client’s
progress is an ongoing process
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Etiology of Dual Diagnosis
• Vulnerability model
– Drug use contributes to mental illness.
– Other factors increase the risk for mental illness.
• Alcohol personality subtypes
• Self-medication hypothesis
– Individuals with psychiatric disorders use drugs to
help them alleviate symptoms.
– Self-medication leads to drug dependency.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Symptoms and Diagnostic
Characteristics
Four major categories
• Primary diagnosis is mental illness; secondary diagnosis,
substance-related disorder.
• Primary diagnosis is substance-related disorder;
secondary diagnosis, mental illness.
• Mental illness and substance-related disorder coexist.
• Substance-related disorder and mood disorder co-occur.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Nursing Process
• Assessment
• Nursing diagnoses
• Outcome identification
• Planning interventions
• Implementation
• Evaluation
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment
• Identify the relative contribution of the most common
coexisting diagnoses: anxiety disorders, depressive disorders,
personality disorders, and schizophrenia
• Sources of data include the following:
– Substance-related disorder assessment tools
– Mental status exam
– Laboratory testing
– Review of court records, medical records, previous
treatment records
– Interview of social worker familiar with the client’s history
– Observation of the client in the clinical setting
– Assessment of the client’s motivation to seek treatment,
desire to change behavior, and understanding of diagnosis
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Diagnoses
• Ineffective health maintenance
• Disturbed thought processes
• Impaired social interaction
• Ineffective coping
• Noncompliance
• Situational low self-esteem
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Outcome Identification
Outcomes focus on the following:
• Willingness to participate in treatment
• Development of positive coping skills
• Verbalization of feelings of increased self-worth
• Development of appropriate social skills
• Desire to establish and maintain contact or relationship
with a professional in the community
• Desire to socialize in drug- and alcohol-free
environments
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Planning Interventions
Interventions are based on the individual’s needs
considering the following:
• The type of substance-related disorder involved
• The presence or absence of cognitive impairment
• The ability to process abstract concepts
• Motivation for treatment
• The availability of social support
• The necessary treatment setting to address clinical
symptoms
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Implementation
• Acute stabilization
• Engagement
• Prolonged stabilization
• Rehabilitation and recovery
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Evaluation
Evaluation focuses on the following:
• Compliance by the client
• Stated outcomes
• Effectiveness of interventions
• Progress the client is making
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Key Terms
• CAMI
• Persuasion
• Dual diagnosis
• Self-medication
hypothesis
• MICA
• MICAA
• Vulnerability model
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Reflection
Reflect on the chapter-opening quote by Vaccaro.
Explain your interpretation of the phrase
“catastrophic life problem.”
• What nursing challenges do
you think you would encounter
if you were to develop a
nursing plan of care for such a
client?
• Do you feel adequately
prepared to provide care for
such a client? Explain your
answer.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
?