“…each disorder exacerbates the other and also predisposes to relapse in the other. At times, the symptoms can overlap or even mask each other, making diagnosis and treatment all the more difficult.”
~Robert B. Pereia, Faces of Dual Diagnosis: A Canadian Perspective
Recovery from a substance abuse disorder such as alcoholism, drug addiction, or the misuse of prescription medications is hard, and it’s made even more difficult when there is a dual diagnosis of a co-occurring emotional or personality condition.
Addictive and personality disorders like anxiety, depression, PTSD, or bipolar disorder share a complicated, mutually-causal and contributory relationship. Look at some startling statistics:
- Half of all people who meet the criteria for a diagnosis of a mental disorder are ALSO addicted to alcohol and/or drugs
- Just OVER half – 53% – of drug addicts have a diagnosable mental condition
- More than one-third – 37% – of alcoholics have a diagnosable mental condition
- Approximately 70% of male and 80% of female substance abusers self-report that their drug/alcohol abuse was preceded by symptoms of anxiety such as social phobias or panic attacks
- At a 6-year follow-up evaluation, students with an anxiety disorder had a risk of substance abuse that was 3.5 times GREATER those without the condition
- Around 42% of male and 53% of female substance abusers suffered from depression prior to developing their addiction
- Non-abstinent patients with depression who also have an SUD experience a depressive relapse twice as often as those with depression only
- Among male PTSD patients, 52% will abuse alcohol at some point in their lifetime, and just over one-third will abuse drugs, while female PTSD patients have abuse rates of 28% and 27%, respectively
- Among schizophrenia patients, there is a 47% chance that they will have a comorbid SUD
- Schizophrenia patients have an elevated risk of an SUD that is over four-and-a-half times greater than those without the condition
- Just under 49% of patients with a borderline personality disorder will abuse alcohol, while 38% will abuse drugs
- Only about 12% of people with comorbid disorders receive treatment for both conditions
Why are Dual Diagnoses So Common?
There are number of causes for the prevalence of co-occurring disorders. Most often, people with mental illnesses use alcohol and drugs as a way of self-medicating:
- Drugs and alcohol temporarily relieve the symptoms of their condition
- Many of the medications that are typically prescribed for mental illness have unpleasant or uncomfortable side effects, so patients will resort to alcohol or drugs as alternatives
Here’s the irony – substance abuse has even more negative effects than any of the medications. When prescribed correctly, medications will help stabilize a person’s moods and thought patterns. Substance abusers, on the other hand, are prone to irrationality, because their decisions and actions are driven by the alcohol or drug. It creates a horrific cycle.
Other factors that may influence the development of comorbid disorders include:
- Genetic predisposition – research has suggested that the genes that increase the likelihood that a person will develop an addictive disorder are the same genes that predispose them to mental illness
- Involvement of similar brain regions – both addiction and mental illnesses often affect the prefrontal cortex, the area of the brain responsible for critical thinking and problem solving
- Environmental factors – Exposure to trauma or stress
- Personal behaviors
How Is a Dual Diagnosis for Comorbid Disorders Determined?
Determining whether or not a person has co-occurring disorders can be difficult. Substance abuse can result in symptoms that resemble those of various mental conditions. Furthermore, these symptoms can manifest both when the person is actively using/intoxicated AND during withdrawal.
- Stimulants – psychosis, depression
- Hallucinogens – delusions, psychosis
- Cannabis – panic attacks, mild depression
- Alcohol – depression, severe anxiety
There is a difference between substance-abuse-induced psychiatric disorders and those that are pre-existing. Those mental illnesses that are caused by drug or alcohol abuse will often lessen or even disappear completely with prolonged abstinence.
On the other hand, pre-existing conditions that persist without intoxicating substance require a dedicated treatment plan that is both in addition to and apart from any substance abuse rehabilitative services.
The Diagnostic and Statistical Manual of Mental Disorders, which is published by the American Psychiatric Association, sets forth the standard criteria used to classify diagnose disorders. According to the DSM-IV, a diagnosis of a previously-unknown primary psychiatric disorder should not be made until the patient has at least one year of sobriety.
Because substance abuse and psychiatric disorders so often overlap, it is critically important that the mental health professional conduct an in-depth mental and physical assessment to determine if any comorbidity exists. In fact, many addictionologists have begun to presume a co-occurring disorder until it can be definitively ruled out.
How Is a Dual Diagnosis Treated?
There are four main approaches to the treatment of a patient with a dual diagnosis:
- Partial treatment involves treating ONLY the primary disorder.
- Sequential treatment involves treating the primary disorder FIRST, and once that position has been stabilized, beginning treatment on the secondary disorder.
- Parallel treatment is when addiction treatment is handled by one mental health professional and psychiatric treatment is handled by another.
The Substance Abuse and Mental Health Services Administration recommends the fourth approach – integrated treatment.
Integrated treatment requires all treatment providers to work together within the framework of a shared treatment philosophy. EACH disorder is treated as the primary condition.
The chief characteristic of integrated treatment is the collaboration between multiple service providers, the patient, and their personal support system. The treatment team might include:
- Substance Abuse Counselor
- Medical Doctor
- School Counselor
- Other Family Members
- Sober Friends
- Alcoholics/Narcotics Anonymous Sponsor
- Social Worker
- Child Protective Services
- Probation Officer
What Are Some of the Specific Services Offered for a Dual Diagnosis?
At this point, it does not matter in which order the two disorders manifested, but rather, how to best go about offering effective treatment. The key to treating comorbid substance abuse and psychiatric disorders is to offer simultaneous services, including:
- Individual counseling
- Peer group therapy
- Couples/family therapy
- Support/fellowship meetings
- Medication for both disorders
- Education about both mental illness and substance abuse
- Practical life skills
- Avoiding triggers
- Coping mechanisms
- Stress reduction
- Overcoming trauma
- Proper nutrition
- Exercise program
- Employment & housing assistance
- Reintegrating into society
- Relapse prevention
What If I Believe I Have Co-Occurring Disorders?
It’s a tricky situation – unless you have already been diagnosed with a psychiatric disorder, it is unlikely that you can know for sure if you meet the criteria for a dual diagnosis. But at the same time, it is quite likely that you DO.
Not all drug and alcohol rehab programs are created equal. Simply put, many are not equipped to properly deal with both the addiction and a co-occurring psychiatric disorder. Conversely, many non-specializing mental health professionals do not have the expertise necessary to treat a co-occurring addiction.
Here’s the bottom line – there are two questions that you MUST ask of any perspective rehab facility or program that you’re considering:
- How do you evaluate the possibility of co-occurring disorders?
- If a dual diagnosis is made, what specific services are offered?
If you’re suffering from any sort of substance abuse disorder, timely, effective treatment can save your life. But if you are also struggling with a co-occurring psychiatric disorder, the only way to maximize your chances of successful recovery and management from both is to only work with experienced professionals who specialize in the treatment of dual diagnoses.