1. Dual Diagnosis Case Studies
Mark Holland PhD
Consultant Nurse
Manchester Mental Health & Social Care Trust
Leeds Dual Diagnosis Network

2. Introduction
Background care cluster 16 (dual diagnosis of severe mental illness and substance misuse)
Cluster 16 needs and treatment guide
Case studies
Dual diagnosis beyond psychotic cluster 16
Discussion and Conclusion

3. Cluster 16 Cluster Description :
This group has enduring, moderate to severe psychotic or affective symptoms with unstable, chaotic lifestyles and coexisting substance misuse. They may present a risk to self and others and engage poorly with services. Role functioning is often globally impaired
Diagnoses:
F (Schizophrenia , schizotypal & delusional disorders)
F30 – 31 (Bi-Polar Disorder)
F32.3 (Severe depressive episode with psychotic symptoms)
Plus/with
F10 – 19 (Mental & behavioural disorders due to
psychoactive substance use)
Risk :
Overdose (intentional/accidental)
Entry into CJS
Harm to self
Harm to others/From others
Course:
Long term – 3 yrs +

4. C 16 Expected Needs Medication management/pharmacology
Health education/harm minimization
Engagement
Motivational interviewing
Social inclusion

5. C 16 Partnership working Substance misuse services (all sectors)
CJS (probation/prisons/police)
Housing
Employment

6. Core Elements of Care Direct
Engagement, Motivational interviewing techniques, CBT techniques, Harm minimisation/health promotion, Assertive Outreach Approach, Medication management, Assistance to increase social functioning, Relapse prevention strategies,
As appropriate, advise/signpost/access self-help (e.g. groups), self-monitoring (e.g. triggers, early warning signs),
Indirect
Supportive & empathic relationships, provide hope

7. C16 Pathway Needs Management of intoxication Mental health relapse
CRISIS MANAGEMENT
Management of intoxication
Mental health relapse
CARE COORDINATION 
Should be under mental health service CPA
Care coordination by someone experienced (level 3 capability framework)
Drug/alcohol relapse
MONITORING OF PHYSICAL AND MENTAL HEALTH
This should be the same as the other psychotic clusters with minimum of neuroleptic therapy NICE guide and attendance to BBV treatments and advice
DETOX & REHAB
Access to detox (complex cases capability)
Admission to appropriate complex needs rehabilitation

8. C16 QUALITY AND OUTCOMES GOALS
Maximise quality of life and physical health
Maintain appropriate contact (SBNT)
Symptom management
Prevent general worsening of condition
Reduce risks (including Safeguarding)
Support recovery hopes (both domains)
Relapse prevention (both domains)
Preventing complications associated with illness and medication as relevant (harm reduction and health promotion/ illness prevention)

9. Case Presentation 1: Christian
General implications and exercise / discussion

10. Demographic 24 year old male Caucasian
Lives between parents and girlfriends
Has a 2 year old child
Has a 14 year old brother
Unemployed for 18 months, prior to onset of psychosis held various ‘blue collar’ jobs
Prison age 20 (violent offence in organised crime, served 3 years)

11. Past History 15-23 Moderate alcohol Cannabis age 15 to present
Initially symptom free
Cocaine age 17 intermittent, no use for past 6 months
Noted by family to be intense in manner and hold emphatic beliefs about Free Masons and Illuminati
Heavier cocaine use late teens
Became involved in crime
No IV use, no BBV’s despite long term shared insufflation
Abstained whilst in prison
No treatment in prison, no reported symptomatology
On release drinking increased
Family raised concerns with GP about growing preoccupation with Illuminati and expression of related paranoid ideas, grandiose flavour

12. Past History 22/23 Concerns Putting out cigarettes on forearms
Isolating himself
Striking his girlfriend
Shouting at family (HEE reaction / household)
Increased alcohol use
Little cocaine or cannabis use
Referred to CRHT, poor engagement both parties but ‘calmer’
Referred to dual diagnosis service (DDS)

13. DDS Presentation Type I Diabetes No residual self harm damage or acts
FTD, True auditory hallucinations, paranoid delusions with grandiose overtones, derealisation, depersonalisation, with ?Capgras syndrome
Generalised anxiety both motor and autonomic
Variable mood (prominent paranoia = low mood versus prominent grandiosity – high mood)
Verbal expressions of anger towards family and girlfriend (HEE environment)
Isolating himself
Alcohol used to avoid/reduce anger and alleviate anxiety
Anxiety correlates to delusional beliefs (even when grandiose)
Disturbed / reversed sleep pattern
Increasing alcohol misuse (relief drinking noted) and complications
Fluctuating rapport from guarded and suspicious to engaging (desperate for help)

14. Provisional Diagnosis and Management
Paranoid Schizophrenia / alcohol induced psychotic disorder with hallucinations and delusions
Alcohol harmful use / dependence syndrome
Neuroleptic Therapy
Vitamin Therapy
Motivational Interviewing
Alcohol education and information
Alcohol reduction / detox (community/ inpt)
CMHT referral
Alcohol Service referral?

15. Exercise In groups or pairs please list the possible additional issues
E.g. Safeguarding, risk to staff, other services for cannabis, cocaine and other drugs, engagement issues, individual / family CBT etc
List issues that have emerged in your practice with similar patients
List services you have referred to or know of that may help Christian

16. Case Presentation 2: Kelly
Motivational interviewing / Cognitive behavioural approach for
distress, symptoms, motivation and coping

17. Overview 29 year old woman 2nd generation African Caribbean
Lives alone in well kept flat
2 friends, one of whom visits 5 times a week
Pet cat
Limited contact with adoptive parents or siblings (all white British) for past 6 or 7 years
Split from them was acrimonious (elements of illness associated)
Diagnosed paranoid schizophrenia 6 years ago
Previous schizotypal personality disorder diagnosed (PD label has stuck)
Receives fortnightly risperidone consta 37.5mg
On 3rd antidepressant
Smokes skunkweed daily
Crack cocaine and heroin smoked as treat fortnightly
Hep C (prior IV use)

18. Mental health distress
Paranoid feelings – constant and pre curser to…
…Paranoid ideation – conviction level increases rapidly when outside among strangers and friends alike
General anxiety – psychomotor and autonomic
Social anxiety / phobia
Marked depression
Anger – specific to adoptive parents or at times of paranoid ideas of reference
Feelings of rage – free floating (and sometimes attached to adoptive family)

19. Paranoid ideation No consistent delusional belief elicited
Feels under constant surveillance but guarded when describing / cannot elaborate (most days, throughout the day)
Manageable when smoking cannabis and in her flat
Ideas of reference from variety of sources when out
Not specific to same individuals or groups
History of violent response (stabbed a male stranger who voices said had raped her)
Accompanied by true auditory hallucinations
Paranoid ideation conviction rating 80-90%

20. Hallucinations Does not recognise voices 2nd and 3rd person
Derogatory, volume and intrusiveness varies
Command
in revengeful mode (rape victim)
Harm self
Occur on majority of days
Coping
Cannabis and isolation = can cope
Cannabis and going out = sometimes cope
No cannabis and out = cannot cope
Mood relieved by crack cocaine and heroin
Voices conviction rating 90%

21. Brief analysis of substance misuse
PROS
Feels chilled - relaxant effect (short lived)
Boosts confidence
Reduces feelings of rage and anger
Enhances music
Something to do
Relieves low mood
CONS
Costly >1 ounce cannabis a week (£100+); much as can afford of crack and heroin
Conflicts with personal image of self reliance and physical fitness (previously fitness instructor)
Feels dependent on it
Artificially relieves anxieties
Artificially creates euphoria
Reduces sleep quality

22. Focus on one ‘PRO’ - Chilled
Voices less intrusive and voluble
Anxiety (autonomic) diminishes
Headaches, physical tension remains quite marked
Paranoid ideation - unchanged in conviction & frequency, less intrusive however
Feelings of rage and anger about family less dominant
Objective – emphasise the self medication aspect that then reappears in a ‘con’

23. Focus on one ‘CON’ – artificially relieves anxiety and improves mood
Demonstrates insight of this maladaptive coping strategy (i.e. Short lived)
“there must be a way I can cope, without drugs, like other people do” led to “I used to manage OK”
Connects ‘artificial’ psychoactive effect to her personal image belief of health and self reliance
“I feel less depressed when I’m stoned but it’s wrong to rely on it….and that thought makes me feel low…especially when I’m no longer stoned”
Both statements demonstrate motivation to change

24. Motivation Necessary prior to cognitive behavioural work
Shared goals and agenda
Building motivation through motivational interviewing
Strategies such as decisional balance matrix (pros & cons)
Principles of empathy, rolling with resistance, developing discrepancies, supporting self-efficacy
Preparation for cognitive work can start at Contemplative stage of motivation

25. MI Preparation established change action maintenance preparation
contemplation
relapse
pre-contemplation

26. Decisional Balance Sheet
Not Change
Change
Good things
Not so Good

27. Importance and confidence10
Readiness to change
Importance 10
Confidence

28. Preparation - Cognitive Model
Affect
View of past
Self-view
Cognitions
Behaviour
View of immediate life situation
View of future

29. Beliefs that predispose to change
My current behaviour is ‘bad’ for me (importance)
I would be better off if I changed (importance)
If I try to change I can be successful (confidence)
This is a good time to do it (readiness)

30. Coming up with a ‘Relapse Cycle’ or case formulation
Beliefs
(cannabis is good for me, need it to get going, relieve tension/ anger, craving)
Trigger/High Risk Situation
(out, paranoid feelings anxiety low mood)
Auto Thoughts
(What the hell! My life has turned out bad)
Susceptibility to Triggers
Cravings / positive anticipation
(physical and psychological – anticipated positive effect)
Sequalae
(dissonance- feel bad / weakened resolve; relief short-lived)
Permissive thoughts
(I deserve not to suffer this tension, it’s not my fault)
Use / lapse / relapse
(relief obtained)
Urge / Focus on Action
(Score, roll joint - relief begins)

31. Beliefs about substances that contribute to cravings and urges
PROCESS
REPLACEMENT BELIEFS
MAINTAINING STRATEGIES
AFFIRMED REPLACEMENT BELIEFS
Anticipatory
Expectations(relief- orientated)
Permissive
Catastrophic
Assess, examine and test out belief
(Socratic questioning, guided discovery)
Not as good as expected
Temporary relief only
I used to do good satisfying things so I could do them again
It’s not my fault but I can do something else
It can improve, this is a lapse not a relapse
‘Cons’ flashcard
Success flashcard
Activity schedule
Supporters / sponsors
Imagery techniques
I can get relief elsewhere / other ways
I can do things OK
I don’t need it.
Document and reference (flash card, anchor memories)

32. Trigger/High Risk Situation Susceptibility to Triggers
Relapse Cycle: Opportunities for Intervention
Beliefs
(good/bad for me, need a joint to get going, relieve tension/ anger, craving)
Trigger/High Risk Situation
(out, paranoid feelings anxiety low mood)
Auto Thoughts
(What the hell! My life has turned out bad)
Susceptibility to Triggers
Cravings
(physical and psychological – anticipated positive effect)
Red – Cognitive
Green - behavioural
Sequalae/ catastrophic
(dissonance- eel bad / weakened resolve, it’s getting worse)
Permissive thoughts
(I deserve not to suffer this tension, it’s not my fault)
Use / lapse / relapse
(relief obtained)
Urge / Focus on Action
(Score, roll joint - relief begins)

33. Considering and selecting symptoms
Mood
Antidepressants, CBT, Counselling, psychotherpay
Cognitive / thinking
Examine (and test) cognitive errors such as personalisation, over generalisation, dichotomous thinking, and harsh self-criticism.
Examine, (test) and reframe core beliefs such as I’m helpless, nothing works for me, I’m alone, I’m stupid, life is empty, it’s good for me, I need it to get going.
Introduce replacement beliefs such as relief is temporary, I used to manage OK without it
Reattribution of responsibility (extrinsic factors to internal factors – empowerment / self-efficacy)
Behavioural
Activity schedule, relapse prevention suicide prevention, social skills- assertiveness, vocational, employment, ‘cons’/ success flash cards, PMR relaxation
Physiological
Sleep hygiene, hypnotics, activities, anxiety management
Motivational
Pros and cons of current use / behaviour (wishes to escape - suicide / drugs), importance & confidence

34. Imagery techniques
STOP (spoken volubly) and MIND’S EYE visual imagery of stop sign, police officer, relative, sponsor
IMAGE REPLACEMENT by empty wallet, hangover, physical injury, poor health, victim

35. Exercise (optional) Groups of 4-6 people Identify an existing clientOr
Create your groups own client
Create a Relapse Cycle
Highlight potential intervention opportunities within the relapse cycle Cognitive / behavioural / social / pharmacological
Make a few notes for a brief feedback (if we’ve time!)

36. A – FRAMES Assessment (thorough but not at expense of engagement)
Feedback (accurate and specific to assessment)
Responsibility (clients but may need graduating)
Advice (accurate, evidenced & neutral)
Menu (of options)
Empathy (avoid confrontation and resistance)
Self – efficacy

37. Conclusion Initial Focus on Engagement Thorough Assessment
Symptom selection
Intervention choice
Motivational Interviewing – Preparation Cognitive-Behavioural Techniques - Action
Timing, perseverance and optimism

38. Did it work?

39. There is an alternative!
Russians thrash drug takers to stop addiction
“On the first day we beat them with belts until their buttocks turn blue.
Every week we have to buy a new belt because they go too soft, but we have been impressed with the quality of Gucci belts.
Drug addicts are animals who have lost all sense of values. This way, the next time they think about getting a fix they remember the pain of the thrashing rather than the rush of the drugs. It's very effective.
You cannot solve this with mild manners - you need tough measures”
City Without Drugs - Igor Varov Reported by Drugscope

40. Dual diagnosis beyond c 16
HONOS substance misuse subscale rating is conventionally substance treatment orientated
SMI & SM often need designating to 16 by care cluster rater
No care cluster for non-psychotic DD (as yet)

41. Honos Substance Misuse Subscale
Item Scoring:
0= None: No problem of this kind during the period rated.
1= Minor problem: Some over indulgence, but within social norm.
2= Mild problem; Loss of control of drinking or drug taking, but not seriously addicted.
3= Moderate problem: Marked cravings or dependence on alcohol or drugs with frequent loss of control; risk taking under the influence.
4= Severe problems: Incapacitated by alcohol/drug problems.

42. End
Any comments
Thank you