Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders

This is the eighth volume in Marcel Dekker’s Medical Psychiatry series, edited by William A. Frosch. It is a comprehensive review of the English-language literature on comorbidity. There are 17 chapters written by 33 contributors. Thirteen of the contributors are colleagues of the editors at the University of Connecticut and Yale University. The first four chapters are devoted to basic issues in dual diagnosis and the remaining 13 to specific disorders that are complicated by alcohol and drug abuse.

Chapter 1 is on the epidemiology of comorbidity. Comorbidity research began less than two decades ago. The authors give us data from general population surveys as well as from treated populations. Chapter 2 discusses explanatory models of nonrandom associations of diseases. Is comorbidity the result of common etiology or are patients with two diseases physiologically different from those with just one? The first section concludes with overviews of diagnostic methods and treatment modalities.

Chapters 5 through 17 deal with the coincidence of substance abuse with anxiety, mood, and personality disorders, schizophrenia, PTSD, attention deficit hyperactivity disorder (ADHD), eating disorders, and traumatic brain injuries. There is a chapter on the triple-diagnosis patient with a psychiatric disorder, substance abuse, and HIV infection. Another explores the addition of nicotine dependence to the picture. The final chapter discusses the medical complications of substance abuse and dependence.

In the chapter on comorbid substance abuse and personality disorders, the authors discuss the different conceptual models of addiction and their implications for treatment and outcome. They look at questions of causality. When does personality disorder cause addiction? Does addiction cause personality disorder? The authors who address comorbid schizophrenia and substance abuse emphasize the special problems in treatment because of the apathy, cognitive impairment, and limited interpersonal skills of patients with schizophrenia. Substances of abuse may appeal to patients with schizophrenia not only because they stimulate pleasure centers in the brain but also because they improve brain functioning temporarily. The three psychologists who are responsible for the chapter on comorbid nicotine dependence and psychiatric and other substance use disorders focus on the role of nicotine in major depressive disorder, schizophrenia, and alcohol abuse. The chapter on traumatic brain injury examines its connections with alcohol abuse in particular, both from the point of view of causation and the effects of alcohol on glutamate and catecholamines in the brain. A group from South Carolina summarizes the research on the overlap of adult ADHD and alcoholism, substance abuse, and personality disorders. The chapter on eating disorders points up a kind of substance abuse that is unique to these disorders, namely, the use of diuretics, laxatives, and emetics. The chapter on comorbid trauma exposure, posttraumatic stress disorder (PTSD), and addictions discusses the current explanatory models. The author also reviews the evidence for neurobiological elements that are common to PTSD and substance dependence.

The foregoing examples of highlights do not nearly convey the impressive scholarship that has gone into this volume. There are 2,500 references to the literature, averaging about 150 per chapter. For the psychiatrist, Dual Diagnosis and Treatment represents a one-stop source of information about and thinking on the phenomenon of comorbidity.