What is Dual Diagnosis?
Dual Diagnosis is also called co-occurring disorders or COD and is generally applied to the co-existence of a mental illness with another condition or disorder, most often substance abuse. However, it may also reflect autism and other mental health conditions, such as anxiety, paranoia, schizophrenia, or depression. The effect of dual diagnosis with autism can be difficult for the individual, as well as the practitioner trying to help.
Trauma affects the autistic brain via the Limbic System, resulting in increased fear and avoidance, while decreasing functionality – resulting in a person who becomes increasingly isolated, and unable to perform the same daily functions and tasks as before the traumatic event that affected the brain. Diagnosis of this combination is not easy, as it does not usually show up in any type of medical imaging. Generally, few diagnosticians will put together the combination of things, but some specialists do know how to identify the event and its effect.
A Case In Point
In June 2010, James was involved as victim of a motor vehicle accident (MVA) that was extremely traumatic, both physically and mentally. During the accident, his head was whiplashed, causing a concussion that remained undiagnosed for years, and consequently untreated. A later diagnosis of Post Concussion Syndrome, a Traumatic Brain Injury (TBI), was finally documented in 2015, as was Post Traumatic Stress Disorder. This event set forth a series of anxiety‐related events, and legal ones. James, being autistic, cannot let go of the accident experience. He progressively became less functional.
As time progressed, James became embroiled in a controversial lawsuit in which various events over a 20 month period added to his emotional traumatic experiences. Among these are a very difficult deposition; a fight for his medical records privacy; and a medical examination by the other party’s doctor that ignored his autism (by intent); and a trial that was very difficult for him.
Each of these things, compounded by the physical trauma, and other factors, contributed to a progressive deterioration of his condition since June 2010, to the point that he has spent more than three and a half years unemployed and is deemed by his diagnosing doctor, therapist and others as unemployable, severely depressed and anxious. He has isolated himself in his bedroom, sometimes not leaving for days; sometimes not eating or drinking for as long as three days, and refusing all verbal communication with others, including immediate family, sometimes for months.
The track record of his job search attempts, after the accident, concurs with a psychiatrist’s diagnosis, that he is unemployable. His autism, anxiety and behavior are evident to anyone meeting him, confirmed by a comment by his lawyer in 2013 about the disclosure of his condition to the judge in that case – that anyone can see his condition. He cannot make eye contact (typical of autism), but taps his head, snaps his fingers, bends, sways, and fidgets during interviews, and often refuses to speak unless directly addressed. One must say “James, please tell me….” or he won’t reply, sitting there as if in another place and time, oblivious until addressed directly.
James’s mental condition is a progressive one with four underlying determinable causes: autism, comorbid anxiety disorder, depression, and traumatic brain injury. The series of traumatic effects upon this combination do not allow healing or dismissal of the events in his mind. They are as fresh today as when each event happened. It is well documented that people with autism see language as a pictorial form of communication, so it should come as no surprise that traumatic events will replay in the mind, endlessly. Temple Grandin has said that she sees things replay in her mind as a video loop, constantly playing.
James not only had bad experiences with the motor vehicle accident, but subsequently with the other party’s insurer, and eventually lawyers (including his own), and a forced medical examination in which the examining doctor tried to create a meltdown to document it as bad behavior. Today, James cannot watch adult‐age television for fear of seeing commercials for law firms or insurers, and requires weeks of groundwork in order to see a new doctor. His fears have increased since the accident, with every little event, and some large ones have added paranoia to his mental issues. He becomes obsessed with some fact or bit of information to the exclusion of all others, and often, this is incorrect or misunderstood. He requires the constant attention of one single friend.
He needs help, but will not likely take any medications. Concussion is recurring due to his autism, in which he repeatedly and forcefully smacks or punches his forehead, often to the point of nosebleeds.
To understand some of what has happened in James’s brain during these events, we need to understand how the brain works, and we will start with the limbic system. The limbic system, which is made up of two structures, the hippocampus and the amygdala, has to do with emotion, memory and other things we will explore in more depth later. For the moment, we are concerned with one of its functions‐responding to danger. The limbic system receives a stimulus; for example, a loud noise. It then has to answer the question, ‘Is this safe?’ The limbic system routes the response process in one of two directions: if safe (the noise is a fire drill) it is going to the cortex to work it out (remember to leave the building through the fire exit, but there’s no need to be afraid, everything is okay).
If not (smoke is pouring under the door), the brainstem will react to it by changing the breathing and heart rate and other basic function systems to prepare for the threat. This also depends on individual perception; someone who has been injured in a fire may still find his or her autonomic systems responding to “danger”, even during a drill. This, in fact, is one way to characterize Post‐Traumatic Stress Disorder: responses that are out of proportion or inappropriate to the situation.
When we feel threatened, the amygdala signals the brain that we are in danger, and floods the brain with adrenaline, norepinephrine and cortisol. These chemicals prepare us to survive the danger by giving us the energy and focus to fight, flee or freeze. Our cortex, which does our abstract thinking and complex decision‐making, is slower to respond when the amygdala is activated. Once we have escaped the threat or realized we are not really in danger, the amygdala calms down, the stress chemicals in our brains subside and the cortex becomes active again, allowing us to think more clearly. If this happens only occasionally, the cortex is “off‐line” only until the danger is over, and recovers quickly and fully after a few seconds.
With occasional repetitions of this circuit, there is little or no change in the brain. If, however, the fear is very intense and happens over and over again, the brain starts to adjust, actually “rewiring” itself and devoting more space to the structures that are used the most. The amygdala and brainstem can become enlarged, and the cortex can compress or shrink. The fear cycle gets faster and stronger, and this makes the fear even easier to trigger and the cortex slower to reactivate. (DeBellis, 2001; Schore, 2003)
If the cycle becomes strong enough, just thinking about the events causes the cycle to start, and over time the cycle can “start itself”. It becomes a vicious circle, as the brain becomes more and more primed to be set off by very little or seemingly nothing to launch the sequence. It’s like an electronic alarm system that is a little over‐sensitive and goes off too easily, and soon stays on almost all the time, or in other instances becomes damaged and fails to go off when it should.
Associations with that fear can become more and more generalized, as in the case of “Albert”. In a classic set of experiments, a little boy (given the pseudonym Albert) was conditioned to fear white rats, though he had never displayed fear of them previously. The first time he was presented with various animals, nothing happened. Then experimenters Watson and Rayner paired the appearance of a white rat with a loud noise, startling Albert.
Eventually, Albert would flinch and exhibit fear when shown the white rat, even without the noise. Over time, the experimenters noticed that Albert exhibited the same phobic behaviors with stimuli that were increasingly unrelated to the original object. Anything white and furry, like a white rabbit, and then anything white or furry (cotton, animals) caused the fearful response. In other words, over time Albert’s brain expanded the list of objects that caused him to react, or as we will see, the “map” in his brain expanded to include wider territory, including more general objects that now caused fear where none existed previously (Watson and Rayner, 1920).
The Impact of Dual Diagnosis
Even when James is not around motor vehicles, lawyers or doctors, James’s brain can be easily reminded of the traumatic events he’s experienced. For James, insurance and medical examinations are closely linked to the experience of the accident and trial. At first, only insurance advertisements that strongly evoke the experience triggered the brain response. As his brain grows more efficient with each trigger, “learning” the fear response, more and more neural space is given to the response. Less space is given to associations with work or entertainment that are neutral or pleasant. Over time, the response generalizes, until almost all connection with unplanned medical visits, lawyers or insurance, vehicle movement (a car changing lanes, or a nearby truck) sets off the fear response.
Despite the fact that he really needs a lawyer for his current Social Security Disability appeal, the thought of hiring, speaking to or in any way hearing about lawyers sends him into a screaming meltdown. He refuses to go before an administrative law judge because he was ‘judged’ in his MVA trial. He cannot disassociate the events of the past with contemporary situations, and cannot see the differences between them. He makes comparisons that are disconnected in the real world, but in his mind, have definite, clear connections. Nothing said to him can convince him two things or events are unrelated.
James’ reaction to bad news that does not directly involve him has often been odd. If he hears about a multi-car crash on the highway, he would giggle, even before his own accident, but really bad news, such as a school shooting would make him sad, even to the point of crying. Since the MVA, his reactions to news events like school shootings have changed. Now, he will break out into extreme laughter, even when lives have been lost, but funny things elicit no response at all. He has difficulty with his feelings, and beyond the typical aspects of autism, his responses to all kinds of things are unusual, sometimes excessive and generally inappropriate. Worse, he’s aware that his responses are not typical, proper or correct, but he cannot alter his behavior.
In his speech patterns before the MVA, he always had repetitive phrases, but since the MVA, the phrases are repeated hundreds of times, sometimes so rapidly that the sounds blur coming from his lips. It’s as if he must get those words out, come what may. He’ll say odd phrases too, that would have no meaning to anyone who doesn’t know him. Even a friend would think them odd. He will say “Pet poodle hard” but he would never harm a dog, so it sounds like he abuses animals to anyone within earshot. I truth, the phrase comes from the loss of a pet poodle in 2014, and his desire to have the dog back to pet, thinking that if he pet the poodle more, she wouldn’t have died. That animal was the only creature he’s ever expressed love for in his entire life.
His voice also changes from sounding perfectly grown up, mature, responsible to infantile in a split second. He will sound like a three year old, whining that he’s sorry (for nothing done wrong), and begging for forgiveness, or asking if he’s done something wrong… things he will ask or say many times, even when he gets a firm answer.
James’ behavior too, has changed. Like most people he would occasionally express an innocent ideation of suicide during periods of frustration. After the MVA, the frequency and ferocity of those expressions has greatly increased. His suicidal threats have risen to a point where he causes fear in others of his intent. In addition to his repeated threats of suicide, he also threatens other things – like the fact that he hates something so strongly that he cannot reasonably endure it any longer. Recently, his threats have taken on the added dimension of saying how he could do something.
His ability to speak is hampered at times by his stress. Meltdowns now last for many hours, and even days due to stress where before they were brief and infrequent. As time progresses and stress increases, they last for days. This is, of course, very bad as he constantly strikes his forehead, and has banged his head several times into his bedroom wall, and even broken a bowl over his head. All these have the potential to create new concussions.
James’s prognosis is poor at this time. With the pairing of TBI and autism, talk therapy alone does not work. He needs years of other therapies combined with talk therapy and possibly medications to help relieve or reduce his stress. Generally, he distrusts medications, and calls any doctor who prescribes them “pill pushers”.
His fears of medical care have grown exponentially over the years, along with other fears that affect daily life. James’ greatest difficulty is finding practitioners who know about his condition. When he does find specialists, all too often they are diagnosticians only, and have huge fees, often without taking any insurance.
James’ biggest problem though, is often the simple task of getting others to understand his dual diagnosis, and sometimes, understanding it himself. He loses sight of the impact of the TBI on his mind, and becomes agitated, frustrated, and often very despondent because he cannot do the things he would like to do.
Lara Palay LISW-S, kindly contributed her expertise to this article.