Co-Occurring Disorders
A co-occurring disorder, formerly known as dual diagnosis, is the co-existence of one or more mental health disorders alongside substance abuse disorders. The term “dual” in dual diagnosis refers to the two co-occurring disorders, but often individuals may have more than two substance abuse or mental health disorders simultaneously. Because of this, the term “dual diagnosis” was changed to “co-occurring.”
How common are co-occurring disorders?
According to statistics, approximately 8 million individuals in the United States have co-occurring disorders. Those with a mental health disorder such as depression or anxiety are more likely than those without one to also have a substance abuse disorder. Co-occurring disorders can be difficult to diagnose as many individuals have an array of symptoms, and often only one disorder is diagnosed and treated. As a result, the individual may not experience much improvement in their symptoms.
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 have an increased risk for developing a substance abuse disorder if diagnosed with the following mental health disorders:
- 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 to have a substance abuse disorder than someone who has no mental health issues.
Dual diagnosis is an outdated term for co-occurring disorders.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.
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 criteria, the classification information, and an explanation of the disorder. The diagnostic criteria include the signs and symptoms that must be exhibited by the individual, and their duration. Additionally, the DSM-5 lists any other conditions that must be ruled out before making a diagnosis of a 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 (MDD) is a common disorder that affects how an individual thinks and feels. It 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 suicidal ideation.
- Generalized anxiety disorder: GAD is characterized by excessive worry over everyday occurrences that are almost impossible to control.
- Bipolar disorder: Also referred to as manic depression, bipolar disorder is a mood disorder characterized by periods of deep depression that alternate with periods of excessive elation or agitation.
- Obsessive-compulsive disorder: OCD is characterized by having unwanted repetitive and persistent thoughts that are intrusive in nature. These distressful thoughts are either repressed or lead to 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 to others. These traits are usually ingrained from childhood or adolescence and carry into adulthood. As a result, they can be very difficult to treat. These maladaptive patterns often will affect every aspect of one’s life, creating havoc in 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 including stupor, confusion, and loss of inhibition. Alcohol and benzodiazepines work on the same receptors in the brain, so when they are used in combination these substances can be even more deadly. Because Withdrawal from alcohol can lead to seizures and death, medical treatment is necessary.
- Marijuana: Cannabis is composed of two main ingredients: delta-9-tetrahydrocannabinol, more commonly known as THC, and cannabidiol, commonly known as CBD. THC produces the mind-altering effects associated with being high, whereas CBD produces the medicinal effects associated with marijuana.
- Cocaine: Cocaine is a recreational substance that is commonly snorted to enhance mood, increase energy, and produce euphoria.
- Heroin: Heroin, an illegal opioid classified as a Schedule I drug by the Drug Enforcement Administration (DEA), produces feelings of euphoria and relaxation. It has strong addiction potential and severely dangerous side effects.
- Prescription opioids: Prescription painkillers can result in addiction. Intoxication symptoms include drowsiness, slurred speech, stupor, and slow, shallow breathing which can lead to death in an overdose. Opioid withdrawal causes excruciating side effects and professional treatment is necessary. Common opioids include morphine, codeine, oxycodone, oxymorphone, methadone, and fentanyl.
- Benzodiazepines: Commonly referred to as “nerve pills” or “benzos,” these pills have been widely used since the 1960s for alcohol withdrawal, anxiety, insomnia, and seizures. Common prescription benzodiazepines include Xanax, Ativan, and Valium. Intoxication symptoms include drowsiness, confusion, slurred speech, and weakness. Withdrawal from benzodiazepines can result in seizures and death.
- Methamphetamines: Meth is a powerful and intense synthetic stimulant that is used to reach a quick high associated with increased energy, euphoria, and productivity. Methamphetamine is a synthetic drug produced in underground laboratories, basements, or kitchens, so its contents and potency can vary widely. Symptoms of intoxication include heightened energy, psychosis, aggressive and violent behavior, and disturbed sleep patterns. With continued use, meth leads to severe dental and skin conditions.
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 a substance abuse disorder. Others may seek out drugs and alcohol in an attempt to “self-medicate” their mental health disorder that developed in early adulthood, or after a physical injury or emotional trauma. 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 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. 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 unsafe sexual behavior
- Hygiene and health problems
Common examples of co-occurring disorders
There is no single combination of co-occurring disorders. Common co-occurrences 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. Both 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 or 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 condition alone. Having co-occurring disorders also increases the likelihood of relapse in these individuals. A worsening mental health condition can result in increased substance abuse and vice versa. The following are 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 many factors. However, general causes of mental health disorders and substance abuse include:
- 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 with an integrative approach, including:
- Medical detoxification
- Psychotherapy
- Family therapy
- Social support groups
- Medications to treat mental health disorders
- Aftercare treatment
- Cognitive behavioral therapy: A therapy that concentrates on patterns of abnormal thinking and distorted beliefs that are the underlying causes for irrational emotions and thought patterns. The key concept of CBT is the idea that thoughts and feelings are directly related to behavior. Therefore, by gaining control of one’s thoughts and emotions, one can better dictate their behavior.
- Dialectal behavioral therapy: A 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: Interpersonal therapy focuses on relationships and social skills that may be contributing to psychological problems such as depression, or substance abuse disorders. Interpersonal psychotherapy works to help individuals identify emotions and where they are coming from, allowing the individual express emotions in a healthy manner, and deal with emotional baggage.
Should co-occurring disorders be treated together or separately?
A substance abuse disorder can be an unhealthy coping mechanism that has developed secondary to an underlying mental health disorder or eating disorder. Therefore, it is important to treat all co-occurring disorders simultaneously, in an effort to prevent any future relapse. If co-occurring disorders are treated separately, then the individual may struggle with symptoms of one condition while fighting to recover from another.
Levels of care for co-occurring disorders
The treatment level of care for co-occurring disorders depends on the duration and severity of the individual’s condition. Detoxification (detox) is generally the initial step in treatment if the individual is currently intoxicated or withdrawing from the addictive 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. At AKUA Mind and Body, a multidisciplinary treatment team includes an array of professionals including intake admission counselors, life skill coaches, therapists, dieticians, physicians, and nurses. All professionals on the therapeutic team are 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 and sobriety after an individual has successfully completed treatment. Therapists and addiction counselors can recommend an aftercare treatment program, such as community group sessions and online support groups.
Recovery is a lifelong process. Even though someone has completed therapy and is learning to cope without dangerous behaviors, continuing some form of aftercare is vital. 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.
Lifestyle goals for treating a co-occurring disorder
Treatment for co-occurring disorders is initially focused on detoxification from the substance, 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 and intimate relationships
- Addressing job skills and work-related issues
- Managing legal issues
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