Co-Occurring Disorders
A co-occurring disorder, formerly known as dual diagnosis is the co-existence of both a mental health disorder(s) and a substance abuse disorder(s). The term “dual “in dual diagnosis referred to two co-occurring disorders but often times individuals will have more than two substance abuse and mental health disorders simultaneously and therefore the term “dual diagnosis” was changed to “co-occurring” in order to reflect this.
How common are co-occurring disorders?
According to statistics, approximately 8 million individuals in the United States have a co-occurring disorder and individuals with a mental health disorder such as depression or anxiety are more likely than individuals without a mental health disorder to also have a substance abuse disorder. Co-occurring disorders can be difficult to diagnosis as many individuals have an array of symptoms and often times only one disorder is diagnosed and treated at the time of admission and the other disorder is left out, resulting in the individual not showing much improvement in their symptoms. As a result, it may take some time for mental health professionals and substance abuse counselors to properly diagnose each co-occurring disorder in the individual client. According to statistics, individuals who have been diagnosed with specific mental health disorders have the following increased risk for developing a substance abuse disorder:
- Antisocial personality disorder: 15.5 percent
- Manic disorder: 14.5 percent
- Schizophrenia: 10.1 percent
- Panic disorder: 4.3 percent
- Major depressive disorder: 4.1 percent
- Obsessive-compulsive disorder (OCD): 3.4 percent
- Phobias: 2.4 percent
These numbers show that an individual who has been diagnosed with antisocial personality disorder is 15.5 percent more likely than an individual who is not diagnosed with any mental health disorder to also be diagnosed with a substance abuse issue.
Dual diagnosis is an outdated term for co-occurring disorders. Both of these terms are sometimes confused with comorbid disorders. Comorbidity is a broad term used to denote the existence of multiple physical diseases or mental health disorders. Co-occurring disorders is specific to substance use disorders and mental health disorders
Addiction is defined as both a physical and psychological dependence upon one or more drugs. Physical dependence is characterized by a tolerance to the drug of choice (needing an increasingly larger dose in order to experience the same desired effect) and developing physical withdrawal symptoms in the absence of the drug. Psychological dependence is defined by cravings for the drug or obsessing over getting and staying high.
Diagnosis and Statistics Manual of Mental Disorders, Fifth edition DSM-5 is the industry standard in the United States for identifying the characteristics of any mental health disorder. For each specific mental health disorder, the DSM-5 offers the diagnostic criterion, the classification information, and an explanation of the disorder. The diagnostic criterion includes the signs and symptoms that must be exhibited by the individual and the duration of time that those symptoms are exhibited. Additionally the DSM-5 also lists the disorders that must be ruled out before making a diagnosis of the specific mental health disorder. Mental disorders are different from developmental disabilities. Developmental disorders, such as autism spectrum disorder and learning disabilities impair social interaction, mobility, language and self-sufficiency.
Examples of common mental health disorders
Depression: Major depressive disorder is a common disorder that affects how an individual thinks and feels and is characterized by sleep disturbance, loss of interest in activities, feelings of guilt, loss of energy, difficulty concentrating, changes in appetite, psychomotor agitation, sadness and suicide ideations
- Generalized anxiety disorder: Characterized by excessive worry over everyday occurrences that are almost impossible to control.
- Bipolar disorder: Commonly refereed to as manic-depressive illness is a mood disorder characterized by periods of deep depression that alternate with periods of excessive elation and irritable mood
- Obsessive-compulsive disorder: Characterized by having unwanted repetitive and persistent thoughts that are intrusive in nature. These distressful thoughts are either repressed or carried out by compulsions, which are repetitive actions in response to the persistent thoughts.
- Schizophrenia: A psychotic disorder that is characterized by auditory hallucinations (hearing voices) and delusions (false beliefs).
- Personality disorder: Individuals with personality disorders have extreme and inflexible personality traits that are distressing to the individual and others. These traits are usually ingrained from childhood or adolescence and carry into adulthood and as a result are very difficult to treat. These maladaptive patterns often will carry into every aspect of one’s life creating havoc in their personal relationships, home life and occupational functioning.
Examples of commonly abused substances:
- Alcohol: Alcohol is the most commonly abused substance in the United States. Alcohol intoxication is similar to benzodiazepine intoxication with symptoms that include stupor, confusion, and loss of inhibition. Alcohol and benzodiazepines work on the same receptors in the brain and therefore when used in combination these substances can be even more deadly. Withdrawal from alcohol can lead to seizures and death and therefore medical treatment is necessary.
- Marijuana: Cannabis is composed of two main ingredients: delta-9-tetrahydrocannabinol, more commonly known as THC, and cannabidiol, which is commonly known as CBD. THC is known to produce the mind-altering effects associated with “high” whereas CBD is known to produce the proposed medicinal effects associated with marijuana.
- Cocaine: An attractive recreational used substance that is commonly snorted intranasally to enhance mood, energy and produce euphoria.
- Heroin: An illegal opioid that is considered a Schedule I drug by the Drug Enforcement Administration (DEA) and has strong addiction potential and severe detrimental side effects.
- Prescription opioids: Prescription painkillers that can result in addiction. Intoxication symptoms result in drowsiness, slurred speech, and stupor and slow shallow breathing which can lead to death in an overdose. Opioid withdrawal results in excruciating side effects and therefore professional treatment is necessary in order to overcome the withdrawal. Common opioids include morphine, codeine, oxycodone, oxymorphone, methadone, and fentanyl.
- Benzodiazepines: Commonly referred to as “nerve pills”, these have been widely used since the 1960’s for alcohol withdrawal, anxiety, insomnia, and seizures. Common prescription benzodiazepines include Xanax, Ativan, and Valium and intoxication side effects include drowsiness, confusion, slurred speech, and weakness. Withdrawal from benzodiazepines can result in seizures and death.
- Methamphetamines: A powerful and intense synthetic stimulant that is used to reach a quick “high” (an intense euphoric reaction to a drug). Methamphetamine is a synthetic drug produced in underground laboratories, basements, kitchens or anywhere that has a stove a few household ingredients. Symptoms of intoxication include heightened energy, psychosis, aggressive and violent behavior, severe dental problems, and disturbed sleep patterns.
What comes first: addiction or mental illness?
All individuals are unique when it comes time to their experience with addiction and mental illness. Some individuals will be diagnosed with a mental health disorder during childhood or adolescence and will then experiment with drugs and alcohol, developing both a substance abuse disorder and a serious mental health disorder simultaneously. Others may seek out drugs and alcohol in an attempt to “self-medicate” their mental health disorder that developed in early adulthood or that developed after a physical injury or emotional trauma later on in life. Some individuals may first develop a substance abuse disorder that grows so severe that it results in a mental health disorder or triggers the onset of underlying symptoms that may otherwise have remained dormant.
Signs and symptoms of co-occurring disorders
The signs and symptoms of co-occurring disorders will vary depending upon the specific mental health disorder and drug abuse of choice. For example, if an individual is struggling with marijuana abuse and schizophrenia, the signs and symptoms of these disorders will be drastically different than those of an individual who is struggling with a cocaine addiction and bipolar disorder. In general, individuals who are living with co-occurring disorders find functioning on a day-to-day basis to be significantly difficult, if not impossible and therefore many will struggle with the following:
- An inability to maintain employment
- An inability to maintain functional relationships
- Legal problems
- Financial issues
- Extreme mood swings or an inability to control their emotions
- Violent behavior
- Suicidal ideation
- Prostitution or sexual deviance
- Hygiene and health problems
Common examples of co-occurring disorders
There is no single combination of co-occurring conditions but rather a wide variety that ranges in severity and duration. Common co-occurring disorders include the following:
- Alcohol addiction and panic disorder
- Major depression and alcohol abuse disorder
- Marijuana addiction and schizophrenia
- Cocaine addiction and anxiety disorders
- Trauma and substance abuse
- Obsessive-compulsive disorder and anorexia nervosa
- Self-harm behavior and opioid abuse
- Binge eating disorder and alcohol abuse disorder
Additionally any specific personality disorder can co-occur with a substance abuse disorder.
Co-occurrence of eating disorders and substance abuse disorders
Eating disorders are also deeply connected with substance use disorders. According to The National Center on Addiction and Substance Abuse (CASA) at Columbia University, up to one-half of individuals with eating disorders abuse alcohol or drugs compared to 9 percent of the general population. Up to 35 percent of drug abusers have eating disorders, compared to 3 percent of the general population. Both eating disorders and substance abuse disorders have a similar underlying mechanism, the obsessive preoccupation with control and are often linked to psychiatric disorders such as depression.
According to the CASA report: “Bulimic women who are alcohol dependent report a higher rate of suicide attempts, anxiety, personality and conduct disorders and other drug dependence than bulimic women who are not alcohol dependent.” There is a strong link between eating disorders, substance abuse and other mental health disorders. Eating disorders and substance abuse disorders often develop as a means to cope with an underlying mental health issue such as depression and anxiety.
Complications associated with co-occurring disorders
Individuals with co-occurring disorders are more likely to have impairments in daily functioning and within their relationships and work life compared to individuals with either a mental health or a substance abuse disorder alone. Having two disorders also increases the likelihood of relapse in these individuals. Furthermore a worsening mental health condition can result in increased substance abuse and vice versa. The following are additional complications associated with co-occurring disorders:
- Hospitalizations
- Financial problems
- Social isolation
- Family problems
- Homelessness
- Sexual and physical victimization
- Incarceration
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What are the causes of co-occurring disorders?
The causes of co-occurring disorders depend on the specific disorder however general causes of mental health disorders and substance abuse disorders are listed below:
- Genetics
- Past history of abuse or trauma
- The loss of a job
- The loss of a loved one
- Abnormalities in brain chemistry
- Disruptions in prenatal brain development
- Poor nutrition
- Exposure to environmental toxins
- Low self-esteem
- Neglect
- Dysfunctional family relations
- Dysfunctional intimate relationships
Treatment for co-occurring disorders
Treatment for co-occurring disorders aims at treating both the mental health disorder and the substance abuse disorder in an integrative approach. Integrated treatment approaches include the following:
- Medical detoxification
- Psychotherapy
- Family therapy
- Social support groups
- Medications to treat mental health disorders
- Aftercare treatment
- Cognitive behavioral therapy: Specifically concentrates on patterns of abnormal thinking and distorted beliefs that are the underlying causes for irrational emotions and thought patterns that can lead to mental illness. This key concept for this type of therapy approach lies within the idea that thoughts and feelings are directly related to behavior and therefore gaining control of one’s thoughts and emotions can better dictate their behavior.
- Dialectal behavioral therapy: Type of psychotherapy that combines parts of cognitive behavioral therapy with principles of mindfulness. Traditional dialectal behavior therapy focuses on concrete behavioral skills for four domains: emotional regulation, interpersonal effectiveness, distress tolerance, and mindfulness.
- Interpersonal therapy: Type of psychotherapy that focuses on the interpersonal relationships and interpersonal skills that maybe causing the individual to have psychological problems such as depression or alcohol abuse disorder. Interpersonal psychotherapy works to help individuals identify emotions and where they are coming from, helping the individual express emotions in a healthy manner, and learning to deal with emotional baggage. Interpersonal psychotherapy is differentiated from other forms of psychotherapy in that it focuses on the personal/relational practices rather than attempting to modify aspects of an individual’s personality.
Should co-occurring disorders be treated in parallel or separately?
The substance abuse disorder can be an unhealthy coping mechanism that has developed secondary to the underlying mental health disorder or eating disorder or vice versa. Therefore, it is important to treat all co-occurring disorders simultaneously or in parallel in an effort to prevent any future relapse. If co-occurring disorders are treated as separate disorders than the individual may struggle with their substance abuse disorder while they are currently undergoing treatment for their mental health disorder.
Levels of care for co-occurring disorders
Similar to treating a substance abuse disorder or a mental health disorder, the treatment level of care for co-occurring disorders depends on the duration and severity of the individual’s signs and symptoms. Detoxification may be the initial step in treatment if the individual is currently intoxicated or withdrawing from the addicted substance. Once the individual has successfully completed detoxification, he or she will enter residential treatment, partial hospitalization treatment, intensive outpatient treatment or outpatient treatment depending on the severity of their disorders.
Who is qualified to treat co-occurring disorders?
Various professionals are qualified to treat different aspects of co-occurring disorders across different medical, therapeutic, and support specialties. A multidisciplinary treatment team includes an array of professionals ranging from intake admission counselors, life skill coaches and therapists to dieticians, physicians and nurses. All professionals on the therapeutic team should be experts in both mental health disorders and substance abuse disorders.
Aftercare and continued therapy for co-occurring disorders
Aftercare consists of successful living in recovery after an individual has successfully completed treatment for their co-occurring disorder. Many therapists and addiction counselors can recommend an aftercare treatment program, which consists of community group sessions and online support groups. Recovery is a lifelong process and even though the individual has completed therapy and is learning to cope with the real world, continuing some form of aftercare is important. 12-step meetings, recovery support groups, online support groups or outpatient therapy sessions are all a great way to discuss feelings, triggers or even relapses that may occur on a regular basis.
Lifestyle goals for treating a co-occurring disorder
Treatment for co-occurring disorders is initially focused on detoxification from the substance abuse of choice and then providing well-rounded psychotherapy approaches to teach individuals healthy coping skills, relapse prevention techniques and healthy lifestyle changes.
Recommended lifestyle changes that promote health and wellness for individuals who are struggling with co-occurring disorders may include the following:
- Improving sleep habits
- Addressing any chronic medical conditions
- Improving communication skills
- Improving nutritional and eating behaviors
- Working on family relationships
- Addressing job skills and work-related issues
- Managing legal issues
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