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What is Dual Diagnosis and Integrated Treatment for Co-Occurring Disorders?

Disclaimer: This article is not intended as a substitute for the counsel of a qualified physician or licensed therapist. This content should be used for purely informational purposes. Please consult your doctor if you have further inquiries on this subject. We intend to impart the most accurate and recent information but cannot make any guarantees.

Addiction is nothing new.

Although we think of the opioid crisis as a recent phenomenon in the United States, China had its own opium epidemic in the 1700s. Recorded history of alcohol addiction in Egypt goes back as far as 3,000 BC. Yet, through all those millenia, no one has yet discovered a cure for addiction. In recent years, however, advancements in dual diagnosis treatment for co-occurring disorders are opening new doors for those who suffer from these conditions.

After centuries of failed attempts at addiction treatment, the medical community discovered a direct link between mental health disorders and substance use disorders in the late 1980s. Although it took a few decades, integrated treatment for co-occurring mental illness and addiction is becoming the most successful and sought-after type of drug and alcohol abuse treatment. The reason why is simple; almost half of everyone who suffers from drug or alcohol use disorder also exhibits symptoms of a mental health disorder, one of which is usually left untreated in traditional clinics.

Almost 8 million people in the United States suffer from co-occurring disorders (comorbidity) and it's not hard to see why. Those who suffer from a psychiatric disorder are not only more likely to develop substance use disorder, they are also at a much higher risk of relapse if treated for one disorder and not the other. Even now that the capabilities of integrated treatment are becoming well-known in the medical community, only 14% of those suffering from comorbidity are being treated for both disorders.

If you or someone you care about exhibits symptoms of both substance use disorder as well as mental illness, keep reading. In this article we'll discuss the importance of integrated treatment for comorbid substance use disorders, how the process works, and who can benefit from it.

What is Dual Diagnosis?

In short, dual diagnosis describes a practice that diagnoses and treats people who suffer from both an addiction and a psychiatric disorder at the same time. The National Survey on Drug Use and Health (NSDUH) found that as many as 45% of those suffering from addiction problems also had a known co-occuring mental health condition, while some other studies show this percentage to be closer to 60%.

Regardless of of the percentage, it is apparent that many, if not most, of those who suffer from alcohol use disorder also have a mental health disorder. The two are are closely connected and intertwined, although it is not completely clear how.

Some mental disorders can certainly increase your vulnerability to addiction, and vise versa. For example, almost half of adults who exhibit symptoms of attention deficit/hyperactivity disorder (ADHD) also abuse drugs or alcohol. In some cases, this type of addiction can result from the stimulant medications prescribed to treat the symptoms of ADHD. Studies have also shown that adults with ADHD are more likely to develop alcohol use disorder, suggesting that this particular mental disorder may lead to a propensity towards developing substance use disorders in general.

On the other hand, long-term abuse of certain substances may also increase the likelihood of developing mental health disorders. Here are some examples:

Despite mountains of research and articles that have been written on the subject, most scientists and doctors cannot prove a direct causality between drug abuse and mental illness (or vice versa), but it is crystal clear that the these types of disorders are intricately interconnected, which is why neither should be treated on its own.

How Common Is Dual Diagnosis?

It is estimated that 18% of Americans suffer from some kind of mental illness. Of those, about half of everyone who has a mental health condition will also suffer from a substance use disorder at some point in their lives, and vice versa, according to the National Institute on Drug Abuse (NIDA)

Almost 8 million people in the United States suffer from co-occurring disorders, and that's only counting those who have reported or sought treatment for their symptoms. In reality, those numbers are probably far greater.

Despite the alarming prevalence of comorbid addiction and mental disorders, only about 14% of those who have them are able to receive the right kind of treatment to care for both conditions. When this fact changes, medical and cultural progress may actually begin to be made in these fields, and more people can achieve some relief from the symptoms of co-occurring disorders.

What Is Self-Medication?

Self-medication is the theory that people with mental illness often seek freedom from the symptoms of their mental or emotional conditions by using substances. One obvious example of this scenario is a person with social anxiety who drinks alcohol to "loosen up" or feel more comfortable around others.

There is plenty of research to support this idea, such as this study by the Drug and Alcohol Dependence Journal that demonstrates the prevalence of those suffering from post-traumatic stress disorder (PTSD) self-medicating with alcohol and nicotine. Later on, we'll go into the most common types of co-occurring disorders, but first it is important to touch on the risks involved in self-medication.

Dangers of Self-Medicating

Self-medicating in any form is dangerous. Even in seemingly benign cases, such as taking antibiotics for a self-diagnosed infection, the harmful consequences of such behavior can have lasting implications on your health.

While legitimate doctor-prescribed medications can help people cope with mental health disorders in countless ways, those same medications can have negative and dangerous side effects if combined with drugs or alcohol. This is one of the major problems that occurs when people with co-occurring disorders self-medicate with illicit substances; those substances can interact with psychiatric medications and create disastrous - even life-threatening - results. These are some risks involved with self-medicating:

  • Possible dangerous interactions or side effects with psychiatric drugs
  • Potentially exacerbating symptoms of mental disorders
  • Overdose
  • Suicidal thoughts
  • Masking the symptoms of serious mental health conditions
  • Forming harmful and long-lasting addictions
  • Legal, social, or otherwise negative repercussions of abusing illicit or illegal substances

What Are the Symptoms of Mood Disorders and Mental Illness?

If you were to crack open a psychology book, you would find hundreds of different mood disorders and types of mental illness. There are some disorders that tend to be more common, which we'll cover in this article. These are the major types of mood disorders and mental health conditions:

  • Depression or depressive disorder - involves long intervals of sadness, fatigue, and/or hopelessness for two weeks or more
  • Bipolar disorder - exhibits interchanging episodes of euphoric, energetic mania and sudden shifts to major depression and melancholy
  • Anxiety disorder - marked by uncontrollable stress and physical anxiety responses to inappropriate stimuli
  • Seasonal affective disorder - a depressive mood that strikes during the seasons when the days are shorter and less sunny
  • Dysthymia - diagnosed when major depressions lasts for two years or more
  • Mania - marked by a period of intense hyperactivity, energy, intensity, and sometimes euphoria or irritability
  • Psychosis - distorted awareness or thinking, such as hearing voices or hallucinations
  • Schizophrenia - involves psychosis, as well as intense paranoia and elaborate delusions
  • Obsessive-compulsive disorder - exhibits unusual and uncontrollable obsessions and rituals
  • Antisocial personality disorder - marked by a lack of compassion, respect, or regard for other people, as well as their rights and feelings
  • Paranoid personality disorder - involves odd or eccentric ways of thinking, such as paranoia and suspicion of others
  • Post-traumatic stress disorder - usually develops after a traumatic event and involves frightening thoughts, memories, or flashbacks
  • Dissociative disorder - characterized by a disconnection between thoughts, memory, consciousness, and reality

Major Symptoms

As indicated by the list above, there are many types of mental illness and mood disorders, and each has its own distinctive symptoms. There are some major warning signs that can can be suggestive of a wide range of mental disorders, however. Here are some symptoms to be aware of:

  • Extreme or long-lasting feelings of sadness and melancholy
  • Unreasonable irritability, anger, or violence
  • Confusion or the inability to concentrate
  • Sudden or drastic changes in libido
  • Extreme fear, paranoia, or guilt
  • Unexplained changes in eating habits
  • Drastic mood swings
  • Consistent alcohol or drug abuse
  • Retreat from friends, family, or social situations
  • Inability to understand, empathize, or relate with other people
  • Sudden or unexplained fatigue and/or insomnia
  • Inability to cope or manage stress and difficult situations
  • Delusions, paranoia, or hallucinations
  • Suicidal thoughts

Polydrug Abuse and Co-occurring Disorders

Just as drug abuse is closely associated with mental illness, polydrug abuse is even more so. In a study by the Mental Health and Substance Use Journal, researchers came to the following conclusions regarding polydrug use and co-occurring disorders:

  • Mental health disorders were present in 59% of patients who engaged in polydrug abuse, as opposed to only 33% of monodrug users.
  • 54% of all patients in the study were polydrug users, and 47% of all patients were also diagnosed with a mental health condition.
  • The rates of rehabilitation dropout for both patients with polydrug addiction as well as those with mental health disorders are much higher than average dropout rates.

Studies like these indicate that polydrug abuse occurs among drug users at about the same rate as co-occurring disorders, a phenomenon that is not a coincidence. They also show that it is more difficult for individuals of both groups to successfully complete a substance abuse treatment program, much less go on to have a successful recovery.

Polysubstance addiction further exacerbates the difficulty for patients trying to overcome co-occurring mental and substance use disorders, calling even more attention to the fact that specialized, integrated treatment for these types of comorbid conditions is essential to success.

Most Common Co-Occurring Disorders

Depression and Substance Abuse

Depressive disorder is the most common type of dual diagnosis that co-occurs with substance abuse. The euphoria gained from consuming drugs or alcohol provides short-term relief from the unpleasant feelings of sadness and hopelessness that plague most depressed individuals.

The most common co-occurring addictions that coincide with depression are heroin addiction and alcoholism, but some correlation exists between depression disorders and most other types of substance abuse as well. Since any type of drug can provide a short high, any of them may be abused by depressed people as a method of self-medication. If left untreated, both the depressive disorder and the substance abuse will usually continue to exacerbate over time, creating a dangerous combination that will eventually augment the symptoms of depressive disorders.

Since drug withdrawal can make the symptoms of depressive disorders worse, the recovery process is generally more difficult. Antidepressants may relieve some of the symptoms of depressive orders and drug withdrawal, but should never be mixed with drugs or alcohol.

Antisocial Personality Disorder and Alcoholism

One of the most complicated mental conditions to treat, antisocial personality disorder (ASPD) creates a high disposition towards addictive behaviors. A study by Marquette University found that 90% of all patients with ASPD suffer from substance use disorders, with alcohol noted as the most prevalent substance used.

It is unclear what causes the tendency of people with antisocial personality disorders to drink heavily, but it may have to do with the need to fit in or get along better with peers. Those with this condition generally start drinking at a young age and refuse treatment of any kind without obligatory or legal measures.

Comorbidity of ASPD and alcohol use disorder is considered one of the most challenging cases for alcohol treatment programs, but the condition has been shown to improve with integrated counseling and cognitive behavioral therapy.

Cocaine and Anxiety Disorder

Anxiety disorders are often marked by debilitating fear, worry, and stress. Since cocaine is a drug that makes the user feel powerful, productive, and in control, it can be an attractive choice to temporarily soothe anxiety symptoms.

In fact, cocaine has the opposite effect. As soon as the high wears off, the cocaine "come down" can increase anxiety and stress, making the anxiety disorder ever worse. In some cases, this effect is so pronounced that some doctors blame post-addiction anxiety disorders on cocaine abuse.

Post-Traumatic Stress Disorder (PTSD) and Opioids

In the case of co-occurring post-traumatic stress disorder (PTSD) and opioid addiction, it is often difficult for clinicians to differentiate the two. Because of similar symptoms and stress responses exhibited by both PTSD and opioid addiction, PTSD often goes undiagnosed in opioid addicts. This can be especially harmful to treatment since these two conditions often coincide.

The co-occurrence of PTSD and opioid addiction has been linked to certain receptors in the brain that recall traumatic memories. Something about the way PTSD patients recall traumatic experiences makes them more receptive to the pleasurable euphoria caused by opioids.

Fortunately, opioid replacement therapy (ORT) can be a successful treatment for comorbid PTSD and opioid use disorder, since it eases the symptoms of PTSD and opioid withdrawal at the same time.

Marijuana and Schizophrenia

Many studies have concluded that people with schizophrenia love to smoke weed, but it is not completely clear why. A group of researchers at the Henquet of Maastricht University Medical Center in the Netherlands found that those suffering from schizophrenia seem to feel amplified effects of marijuana, enjoying its buzz more than the average user while also experiencing more intense psychoactive effects as well.

While schizophrenics may turn to weed for its intensified effects, they may also be intensifying their own mental illness. Not only does marijuana make schizophrenic symptom worse, it can also bring on the onset of psychosis and/or schizophrenic symptoms in previously healthy patients. Those who have a predisposition or medical history of psychotic conditions should avoid using marijuana at all costs.

Panic Disorder and Benzos

The link between panic disorders and benzodiazepine addiction is no mystery. Benzodiazepines (benzos) are the most common medications prescribed to treat panic disorder and other severe anxiety disorders. Since these medications must be taken on a daily basis to treat a chronic panic disorder, addiction is sometimes a natural consequence of taking daily benzo medications over time.

If a patient who has been prescribed benzos becomes addicted, they will often begin to abuse the pills, leading to long-lasting damage to the brain and body, as well as possible overdose. If a dependence to benzos does occur, the patient will need to detox from the use of benzos and seek out other, integrated treatment plans for both the addiction and panic disorder.

Obsessive-Compulsive Disorder (OCD) and Marijuana

In an article published by the Addictive Behaviors Journal, researchers found that the more severe obsessive-compulsive symptoms were among subjects, the more they were inclined to abuse marijuana.

When questioned, people with obsessive-compulsive disorder (OCD) say they turn to weed and alcohol to help them relax and self-medicate their own symptoms. Abuse and dependence occurs when people use these substances to the extent that they no longer feel normal without them and can no longer function without the help of substances.

Coping with the symptoms of OCD after addiction can be a challenge, requiring specialized treatment that takes previous substance abuse into account.

Stimulants and Attention Deficit and Hyperactivity Disorder (ADHD)

This is another co-occurring disorder in which the treatment becomes the addiction. Prescription stimulants like Adderall and Ritalin are commonly prescribed for attention deficit disorders (ADHD) but present a potential for abuse, especially among adolescent and college-aged individuals.

As many as 60% of those who are prescribed stimulants in college will abuse the medications or mix them with alcohol and other substances. Of those that abuse prescriptions, more than 30% go on to abuse illicit stimulants like cocaine.

During treatment for co-occurring ADHD and substance use disorder, clinicians are challenged to find nonstimulant medications and other types of therapy to treat both conditions.

Bipolar Disorder and Cocaine/Alcohol

Bipolar disorder combined with substance use disorder is one of the most common co-occurring conditions, since different substances can seem to mellow or cancel out the extreme ups and downs of bipolar disorder. It is not unusual for people with bipolar disorder to use cocaine or "uppers" when they're are in a depressive phase of the bipolar spectrum, and then turn to alcohol or other "downers" during a manic phase.

The justification behind this kind of substance abuse is that the different substances may help someone to feel more normal during manic or depressive phases, but the effects are dramatically temporary. Once the immediate effects of the substances have faded, the symptoms of bipolar disorder will only be more pronounced and often longer-lasting due to the consequences of substance abuse.

The Difficulty in Diagnosing a Co-Occurring Disorder

One of the greatest impediments to dual diagnosis treatment is the complicated nature of comorbid diagnosis itself. Drug abuse and mental illness weave such a complicated web within the psyche, mentality, and behavior of a person that it can be very difficult to determine where one ends and the other begins.

For example, people who abuse psychoactive drugs may exhibit many of the symptoms of psychosis while those who take stimulants could show signs of depressive or anxiety disorders. Since long-term drug abuse, sleep deprivation, and withdrawal symptoms can all create circumstances that mimic mental illness, some clinicians must wait until the drug detox stage is over before making an accurate dual diagnosis. In these cases, it is often more effective to treat the immediate symptoms of drug or alcohol withdrawal first, before moving on to other types of integrated treatment.

Why Co-Occurring Disorders Are Treated Differently

In general, people with comorbid psychological disorders and addiction have shown less success using traditional drug rehab methods. This is because the symptoms of mental illness can make the drug withdrawal and rehabilitation process even more difficult than usual. Add that to the fact that drug and alcohol withdrawal symptoms can be markedly more severe for people with mood disorders, and you have a recipe for disaster when the same old drug treatment procedures are applied.

Another factor is that many patients who seek help for substance use disorders have never been officially diagnosed or treated for their co occurring disorders. Especially in cases where mental illness attributes to the addiction itself, it is unreasonable to assume that treating the addiction alone could be successful without also treating the mental illness that caused it.

This is where integrated treatment for co-occurring disorders comes in. In order to improve the symptoms of mental health conditions and substance dependence at the same time, both conditions must be treated simultaneously using a comprehensive approach.

How Is Dual Diagnosis Treated?

The dual diagnosis definition of care is called integrated treatment. This is an individualized approach that seeks to address both substance use disorders and mental health disorders at the same time. Since each comorbid diagnosis is different, each person would need to be provided with a customized integrated treatment plan that takes into account all of their symptoms, both those caused by mental disorders and those caused by addiction. In order to provide this level of care, a dual diagnosis treatment center would need to offer a specialized team of psychiatrists, therapists, counselors, and support staff to address the different needs of comorbid patients.

COSIG grants sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) have been integral to this field, providing funds, training, and supplies to help hundreds of drug rehab facilities across the nation make the transition into integrated drug and alcohol treatment centers.

What Should I Expect from Dual Diagnosis Treatment?

If you or someone you know has been given multiple diagnoses of mental health and substance abuse disorders, you may be wondering what to expect from integrated dual diagnosis treatment. Some of the central components of dual diagnosis treatment include:

Medically Assisted Treatment (MAT)

While a variety of prescription protocols can be helpful during drug detox and drug rehab, prescription medications may be even more important during integrated dual diagnosis treatment.

For one thing, medications like antidepressants and anti-anxiety drugs can play an important role in balancing out the symptoms of mental illness. When psychological medications are safely (and carefully!) combined with other medical detox prescriptions like opioid replacement therapy, the resulting reduction of mental illness symptoms and withdrawal symptoms can result in a much more bearable and successful recovery process.

Medical intervention as dual diagnosis therapy is a delicate balance that must be carefully managed by specially trained doctors to prevent potential side effects and drug interactions.

Cognitive Behavioral Therapy For Mood Disorders and Addictions

Cognitive behavioral therapy (CBT) is the process of exploring and identifying unhealthy, illogical, and destructive thought patterns or beliefs. Once these types of ideas and thoughts have been identified, they can be restructured to create healthier, more productive views and behaviors.

CBT can be used to address addictive thought patterns as well as emotionally unhealthy behaviors and views. In this way, dual diagnosis CBT is specially formulated to treat both substance use disorders and mental health conditions at the same time.

Motivational Enhancement Therapy

Since treatment program completion rates for people with dual diagnoses is dismally low in some cases, motivational enhancement therapy is a way for people to find their "why". In other words, it's a method of soul searching to discover the true reasons and motivations that each addict has for getting sober.

It often happens that patients simply drop out or walk away from integrated treatment programs because facing one's demons can be incredibly difficult and painful. Motivational enhancement therapy helps the patient to dig deep into their own wants and needs to rediscover their intuitive drive to seek recovery.

Contingency Management

Contingency management is a fancy way of saying rewards-based treatment. Although it sounds too easy, this system harkens back to a human's basic need for praise and approval. To put it even more simply, it's a grown-up sticker chart.

In a contingency-management program, patients are rewarded for their continuing progress and sobriety with cash rewards, vouchers, services, or other sought-after prizes. This serves several purposes. First, it helps condition the patients to equate sobriety and recovery with positive, jubilant emotions. The program also gives patients extra motivation and enthusiasm to continue through the difficult recovery process.

Although contingency management was originally developed for drug rehab programs, it has also shown good results during dual diagnosis treatment. In general, patients with co-occurring disorders have much lower completion rates than those with only one type of disorder. Studies show that contingency management initiatives can increase the completion rates of comorbid patients by as much as 50%.

Holistic Solutions

Holistic therapy has positive results for most people, whether they suffer from mental illness, drug addiction, or simple everyday stress. Relaxing activities such as yoga and meditation help patients to become centered and comfortable in their own post-addiction bodies, while other holistic practices focus on whole-body healing and healthy lifestyle changes.

Holistic solutions are healing for the mind, emotional health, and the body as a whole, helping to prepare patients with comorbid mental health and addiction disorders to build a healthier, more positive lifestyle for the future.

How Do I Know if I Have a Problem with Alcohol or Drugs?

Sometimes the lines can seem blurry between "recreational drinking or drug use" and actual drug or alcohol abuse. First, if you have to ask whether or not your substance use is problematic, you may already be too close to the line. Here are some warning signs to look for if you suspect that you or a friend may have a dangerous problem:

  • Drinking or using more than you intended to
  • Seeming to lose control of how much you consume of a substance
  • Using or drinking to the point that you "black out" or suffer short-term memory losses
  • Experiencing guilt or shame in regards to your drug or alcohol use
  • Feeling the need to use or drink in order to "wind down" or feel relaxed
  • Lying to people about your substance use habits
  • Neglecting responsibilities or social outings because of alcohol or drugs
  • Legal problems or fines associated with drug or alcohol use
  • Using during dangerous situations, such as before driving or swimming

To put it in the most basic sense, if you are noticing problems and complications in your everyday life due to alcohol or drug use, you have a problem. Especially if you have tried to cut down or quit using, but were unable to, it is time to seek treatment. It is never too early or too late to ask for help, but ideally you will reach out before your substance use further damages your life and relationships.

How Can I Stop Drinking or Using Drugs?

Addiction develops when your brain and body no longer feel "normal" or functional without consuming drugs or alcohol. Another indicator of dependence is the occurrence of withdrawal symptoms when you stop using. Once you have reached this point, quitting will not be easy.

Drug or alcohol withdrawal is a painful, distressing, and sometimes dangerous process. If you have attempted to go through it alone, you already know just how difficult it can be. Even after this initial phase is complete, your battle with addiction will not end when detox ends. Substance use disorder is a lifelong, chronic disease that can and will affect you for the rest of your life.

If you have tried and failed to quit before, every failed attempt is potentially more dangerous. Not only is drug withdrawal dangerous in and of itself, relapse is even more dangerous, greatly increasing your chances of overdose. If quitting is difficult for you, the safest, most effective way will be to seek the help of licensed doctors and trained professionals. With the help of a drug and alcohol treatment center, the process will not only be more bearable, it will also be safer and more likely to succeed.

Warning Signs of a Co-Occurring Disorder

If you've read this far, it is likely that you or someone you know is suffering from co-occurring mental health and substance use disorders. Without a formal diagnosis however, it may be hard to decide what a co-occuring disorder looks like. Symptoms will vary greatly between different mental health conditions, of course, but there are some general warning signs to watch out for:

  • Alarming or erratic behavior
  • An inability to keep up with daily responsibilities and everyday tasks
  • Deteriorating performance at school or work
  • Extreme changes in behavior and moods
  • Apparent cognitive changes or deficits
  • A sudden or unexpected aversion to social situations and planned activities
  • Disregarding hygiene and healthy habits
  • Suicidal thoughts or tendencies
  • Difficulty managing money and finances
  • An inability to comply with drug treatment, counseling, or other therapeutic programs

How Much Does Dual Diagnosis Treatment Cost?

The first question most patients ask a dual diagnosis treatment facility is, "How much does integrated treatment cost?"

Unfortunately, there is no ready-made answer to this question. Integrated treatment for co-occurring disorders is a highly individualized process that will be changed and adapted according to the mental disorders and type of substance addiction suffered by each patient.

Factors like health insurance coverage, length of treatment, and type of treatment program will affect the final out-of-pocket cost of dual diagnosis treatment. The quickest and most accurate way to investigate pricing for your particular case is to call an addiction hotline and setup an initial consultation.

Get Help for a Dual Diagnosis

If you suspect that you or a loved one is suffering from comorbidity, time is of the essence. Co-occurring psychological disorders and alcohol or drug addiction will usually continue to exacerbate and degenerate until they are both addressed, treated, and overcome with comprehensive and integrated methodologies.

There are a great many challenges that affect patients with comorbid disorders - even more so than with drug addiction alone or single mental disorders - but current research and recent advancements in integrated treatment make the process more effective and attainable with each passing day. Don't let another day pass while suffering from the multiple hardships of mental illness and addiction. Licensed experts are waiting to provide the help and tools you need to free yourself from the symptoms and pain of co-occurring disorders. What's your Day One?

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