This thesis will discuss the topic of comorbid disorders in relation to addiction, from a psychoanalytic viewpoint. Comorbidity or comorbid disorders, refers to two or more disorders being exhibited by the same individual, for example, an addict who suffers from a depressive disorder, or an anxiety disorder. Within the field of addiction, this phenomenon is often referred to as cases of "dual diagnosis". Often it is a controversial topic, as treatment staff get so involved in "duelling" over the actual diagnosis, that the individual may get lost in the process. This is especially the case within the "Minnesota Model" of treatment, one that is extremely popular within Ireland today. This model states that drug addiction is a primary disease, which can only be treated through complete abstinence from all mood-altering substances. Hence, this therapeutic model draws extensively upon the disease model of addiction; this being the framework of Twelve Step Treatment Programmes such as Alcoholics Anonymous, or Narcotics
Anonymous. Whilst this is a valuable form of treatment for many addicts, it results in those who require psychiatric medication often being refused treatment within these centres, as they do not fit the criteria of being drug free. As an addiction counsellor working with "dually diagnosed" clients I have often seen this happen, along with those who are admitted into addiction treatment being treated for their addiction, but not their "other" disorder. That is most treatment centres are based on one particular view of addiction, which treats addiction only, there is no space for any other treatment modality that falls outside of this. Though we must note that the term "addiction" is constantly growing in relation to the various disorders it refers to, this currently includes, alcoholism, substance dependency, sexual addiction, eating disorders, and various other compulsive behaviours such as shopping addictions. From a psychiatric viewpoint, comorbidity is a general occurrence. That is within a psychiatric framework, there is room for the existence of two of more disorders, and a willingness to treat whatever disorders are present. However, within this framework these disorders are diagnosed based upon the diagnostic manuals such as the ICD-lO or the DSM-IV -TR, both of these manuals provide proto-typical guidelines for diagnosing disorders. However, in the attempt to be objective, these manuals have missed the subjective nature of psychopathology, an emphasis that we believe is essential in recognising and treating these disorders. Moreover, the effects of drug use or withdrawal can mimic psychiatric symptomatology, or indeed mask a psychiatric disorder.
Therefore, the focus of this thesis is to review the current psychological and psychiatric data available in relation to comorbidity, clinical assessment, and diagnostic criteria, arguing that this approach to psycho-diagnostics misses a fundamental element that exists within the context of the treatment, which is the transference. Our argument will propose an alternative diagnostic framework, one that allows for the subjective nature of psychopathology; in other words, we shall argue that a diagnosis can be established on the basis of the speech of the client, and the transferential relationship between the clinical and the client. In order to achieve this, we will start by reviewing the pertinent psychological and psychiatric literature available on dual disorders, clinical assessments, and diagnostic frame-works. However, at this point we must note that to review every possible variation of comorbidity would go beyond the framework of this thesis; hence, we have chosen to review depressive disorders, anxiety disorders, and psychotic disorders in relation to addiction. Following this we will discuss the concepts of normality, abnormality, and psychopathology from both a historical and philosophical perspective drawing upon the work of Michel Foucault, Georges Canguilhem, and Thomas Szasz. From here we will discuss the notion of psychodiagnostics from a psychoanalytic viewpoint where we will emphasis the nature of a structural diagnosis, drawing upon the work of Sigmund Freud and Jacques Lacan. This wil11ead us to a discussion of addiction where a structural diagnosis can be established on the basis of the concept of administration as developed by Dr. Rik Loose. We will then discuss the diagnosis of depressive disorders, anxiety disorders, and psychosis from a psychoanalytic perspective, in order to conclude with our observations to date on this highly complex issue.