Clinical Assessment

of Dual Disorder
SPADA
USIM
 DSM-5 DIAGNOSTIC CRITERIA FOR
DRUG USE DISORDER
• Combines “dependence” and “abuse” into “substance use disorder” and
the disorder is assessed based on a continuum – mild, moderate, severe
• Regardless of the particular substance, the diagnosis of a substance use
disorder is based upon a pathological set of behaviors related to the use
of that substance.
• These behaviors fall into four main categories:
 A set of pathological behavior
1. Impaired behavior
• Using for longer periods of time than intended,
or using larger amounts than intended;
• Wanting to reduce use, yet being unsuccessful
doing so;
• Spending excessive time
getting/using/recovering from the drug use;
• Cravings that are so intense it is difficult to think • Important and meaningful social and recreational activities
about anything else.
2. Social impairment
• People may continue to use despite problems with work,
school or family/social obligations. This might include
repeated work absences, poor school performance, neglect
of children, or failure to meet household responsibilities.
• Someone continues substance use despite having
interpersonal problems because of the substance use. This
could include arguments with family members about the
substance use; or, losing important friendships because of
continued use.
may be given up or reduced because of substance use. A
person may spend less time with their family, or they may
stop playing golf with their friends.
 A set of pathological behavior
3. Risky Use
• Repeatedly uses substances in physically
dangerous situations. For instance, using alcohol
or other drugs while operating machinery or
driving a car.
• Continue to use addictive substances even
though they are aware it is causing or worsening
physical and psychological problems. An
example is the person who continues to smoke
cigarettes despite having a respiratory disorder
such as asthma or COPD.
4. Pharmacological indicators; Tolerance &
withdrawal
• Tolerance occurs when people need to increase the amount of a substance to
achieve the same desired effect. Stated differently, it is when someone
experiences less of an effect using the same amount. The "desired effect" might
be the desire to avoid withdrawal symptoms. On the other hand, it may be the
desire to get high. People experience tolerance differently; i.e., people vary in
their sensitivities to different substances. Specific drugs will vary in terms of
how quickly tolerance develops and the dose needed for tolerance to develop.
• Withdrawal is the body's response to the abrupt cessation of a drug, once the
body has developed a tolerance to it. The resulting cluster of (very unpleasant
and sometimes fatal) symptoms is specific to each drug. We discuss these
specific symptoms in each substance category. Although withdrawal is very
unpleasant, it does not usually require medical assistance. However, withdrawal
from some drugs can be fatal. Therefore, consult with a medical professional
before attempting to stop drug use after a period of heavy and continuous use.
This will ensure that quitting is as safe and comfortable as possible.
 10 Separate Classes of Drugs

Hallucinogen
Alcohol Caffeine Cannabis Inhalants
s

And other
Opioids Sedatives Stimulants Tobacco
substances
 Gambling disorder
Non- Internet gaming
Substance
Sex addiction
Related
Disorder Exercise addiction
Shopping addiction
 • Substance-Use Disorders

Groups of Patterns of symptoms resulting from the used of a

substance that individual continue to take, despite

Substance experiencing problems as a result

• Substance-Induced Disorders
related- Including intoxication, withdrawal, and other substance/
medication-induced mental disorders, are detailed
Disorder alongside substance use disorders
 Drug Use Disorder
Diagnosis – (F11.10) Mild Opioid Use Disorder
(F11.20) Moderate Opioid Use Disorder
(F11.20) Severe Opioid Use Disorder
 How to Diagnose?
• Understand Opioid Use Disorder diagnostic criteria

• A minimum of 2-3 criteria is required for a mild substance use disorder

diagnosis, while 4-5 is moderate, and 6-7 is severe (APA, 2013).
• Opioid Use Disorder is specified instead of Substance Use Disorder, if
opioids are the drug of abuse.
1. Taking the opioid in larger amounts and for longer than intended
2. Wanting to cut down or quit but not being able to do it
3. Spending a lot of time obtaining the opioid
4. Craving or a strong desire to use opioids
5. Repeatedly unable to carry out major obligations at work, school, or home due to opioid use
6. Continued use despite persistent or recurring social or interpersonal problems caused or made worse by
opioid use
7. Stopping or reducing important social, occupational, or recreational activities due to opioid use
8. Recurrent use of opioids in physically hazardous situations
9. Consistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological
difficulties from using opioids
10. *Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired
effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished
effect when used appropriately under medical supervision)
11. *Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal
(Does not apply when used appropriately under medical supervision)
*This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical
supervision
 Severity and Specifier
• Severity
Mild : 2 – 3 symptoms
Moderate : 4 – 5 symptoms
Severe : 6 more
• Specifier
In early remission (min. 3 months to less than 12 months)
In sustained remission (min. 12 months or more)
On maintenance therapy
In a controlled environment
 Tentative Diagnosis
• According to DSM 5

(F11.20) Severe Opioid use disorder, in a controlled environment

 Assessment of Dual Diagnosis
The possible relationships between addictions and psychiatric symptoms or disorders
can be seen from the following:

(according to McDowell & Spitz, 1999):

1) Primary mental Illness
Many psychiatric disorders can lead to symptoms associated with many addictions.

Example:

Depression Alcoholism

Pathways: Self-soothing, self-medicating, self-damage

2) Primary Addiction, including Withdrawal
Symptoms
Many addictions can lead to symptoms associated with almost any psychiatric
disorder.

Example: Alcoholism Depression

Pathways: Physiology, behaviour, cognition

Simultaneous and Independent
Conditions
One disorder may prompt the emergence of the other, or the two disorders may exist
independently.

Example:

History of Depression (inc. family)

History of Alcoholism (inc. family)

Interaction pathways as above

Example of Co-Occurring Disorders
• ADDICTION DISORDERS
• Alcohol Disorder
• Cocaine/
• Opiates
• Marijuana
• Polysubstance combinations
• Prescription drugs
• Others …
• MENTAL DISORDERS
• Schizophrenia
• Bipolar Disorder
• Schizoaffective
• Major Depression
• Borderline Personality
• Post Traumatic Stress Disorder
• Social Phobia
• Others..
Clues to Primary Problem (Primary
Diagnosis)
Which diagnosis came first??

• Began before serious secondary problem

• Persists during remission periods of secondary problem
• Severity of symptoms in relation to moderate levels of secondary problem
• Chronic, acute, uniqueness of symptoms
• Family history
 Dimension

Severity of
Chemical Dependency
High
LH HH
2

1
Severity of
Psychiatric Low 4 3
High
Condition

LL HL

Low
 How do you 1) Meet the criteria - Memenuhi kriteria simptoms
know symptoms dari segi definisi dan bilangan

are qualified to 2) Duration - Mencukupi tempoh

3) Dysfunction - Simptom berlaku dengan ketara
be called sehingga mengganggu fungsi kehidupan klien
diorder? tersebut – aspek peribadi/ perhubungan/ dan
pekerjaan
Syarat Sah
4) Exclusion – tiada penyakit lain yang mimik mental
Diagnosis disorder
What to do
in order get 1) Sejarah klien
full 2) Mental status exam

assessment 3) Pemeriksaan fizikal (laporan dari doktor)

4) Penilaian berkaitan, e.g., ujian darah (jika
relevan)
Rukun
Diagnosis
 Confusing symptoms
In practice – develop an initial diagnosis and then will review at a later date
Things to rule out in diagnosis
assessment
1. Malingering and factitious disorder
2. Rule out substance etiology (drug abuse and prescribed medication)
3. Rule out a disorder due to medical condition
4. Determine the Specific Primary Disorder(s)
5. Differentiate Adjustment Disorders From the Residual Other Specified or Unspecified
Disorders
6. Establish the Boundary With No Mental Disorder
Factors that may Influence a Diagnosis

1. The expertise/experience of the professional making the diagnosis

2. The definition of the psychiatric disorder that is used (professional often
disagree on this)
3. The perspective of the assessment team (either from mental health or
substance abuse field)
 Assessing and Managing Risks

Intention
Means
Plans
Protection factors