Understanding Dual Diagnosis

A person is considered to have a dual diagnosis or co-occurring disorder when they have a mental disorder as well as a problem with alcohol or drugs. According to the results of the National Survey on Drug Use and Health (NSDUH) conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), about 9.2 million adults in the U.S. had a mental illness and a substance abuse disorder in 2018. Researchers estimate that about half of people living with a mental disorder will also deal with a substance abuse disorder (and vice versa) at some point in their life.

The Link Between Substance Abuse and Mental Health

While mental illness and substance abuse often affect one another and can occur at the same time, one does not necessarily cause the other. Researchers are not certain of the relationship between these diagnoses, but they believe the link comes down to:

1. Common risk factors

• Genetics, stress, and trauma are all risk factors that can lead to both a mental disorder and substance abuse.

2. Drug use to self-medicate

• Likewise, an individual with a mental disorder may also abuse drugs or alcohol in an attempt to temporarily manage their mental health issue.

3. The effect of substances on the brain

• Finally, the way that drugs and alcohol interact with the brain could lead to changes in the brain that increase the odds of someone developing a mental disorder in the future.

Many people struggling with both a mental disorder and substance abuse dual diagnosis do not receive treatment at all or don’t receive treatment for both issues. Unfortunately, receiving treatment for only one disorder, or focusing on one condition over the other, is not enough to achieve lasting recovery from a dual diagnosis.

Causes and Risk Factors For Co-Occurring Disorders

According to the National Institute on Drug Abuse (NIDA), the mental disorders that most commonly co-occur with drug abuse are:

• Depression
• Bipolar disorder
• Attention-deficit hyperactivity disorder (ADHD)
• Psychotic illness
• Borderline personality disorder
• Antisocial personality disorder

They also add that “the overlap is especially pronounced with serious mental illness (SMI)” and cites three potential factors that increase a person’s odds of developing a dual diagnosis. Let’s take a look at each of these risk factors.

1. Environmental factors

• Environmental factors such as stress, trauma, and negative experiences in childhood can factor into a person’s likelihood of developing a dual diagnosis. For example, the hypothalamic-pituitary-adrenal (HPA) axis is where the body processes stress. When stress levels are high and constant, the HPA can actually decrease behavioral control and increase impulsivity.
• Trauma is another factor that can increase the odds of a dual diagnosis. Whether they had a childhood experience or something happened to them in adulthood, someone who has been physically or emotionally traumatized has a much higher chance of abusing substances. In recent years, this has been especially true for service members with PTSD.
• According to NIDA, “Between 2004 and 2010, approximately 16 percent of veterans had an untreated substance use disorder, and 8 percent needed treatment for serious psychological distress (SPD).”

2. Areas of the brain

• Mental illness and substance abuse on their own can both alter parts of the brain. This means that alcoholism could impact the parts of the brain that control decision-making, impulse control, and emotions, resulting in the development of mental illness.
• Likewise, mental illness can disrupt how substances like dopamine and serotonin are created and transmitted through the body, resulting in substance abuse.

3. Genetic predisposition

A person’s chances of developing a mental disorder and a substance abuse problem may be linked to their genetic makeup anywhere from 40 to 60% of the time. For example, a person with a certain gene variant who regularly uses marijuana as a teenager is at a higher risk of developing psychosis as an adult compared to someone who regularly uses marijuana and doesn’t have that gene variant.

There is still much to learn about how certain genes can predispose someone to addiction or other health concerns. Additionally, environmental factors can further affect genes and cause changes on the molecular level. Chronic stress, trauma, or drug exposure can change someone’s behavior by altering circuits in the brain.

Changing Perspectives on Dual Diagnosis

Dual diagnosis was first identified in the 1980s. Since then, it has also come to be known as co-occurring disorders (COD), the preferred terminology of SAMHSA. Before the diagnosis was first conceived, people were treated for either their mental health issues or their substance abuse but not both at the same time. As a result, there was a low success rate from the treatments.

Past Treatments

• Before the 1990s, researchers believed that people needed to deal with one area of concern before they could move on to their other issue. Typically, this meant trying to address substance abuse before tackling mental health issues. This approach did not prove successful for very many individuals with a co-occurring diagnosis.
• Another approach offered treatment for both conditions, but the two approaches were often conducted by separate individuals who did not communicate about their treatment plans. The person with the dual diagnosis would often receive treatment for their mental disorder from a psychiatrist while discussing their addiction with a therapist. This could lead to the psychiatrist prescribing medication that could interfere with the person’s progress with their therapist.

Medical vs Holistic Approaches

• While neither of these treatments proved very effective, another issue was how those in the psychiatric field commonly viewed substance abuse issues through the lens of medicine and didn’t take into account other holistic aspects.
• Leading treatment programs now understand that dual diagnosis challenges are worsened by environmental factors, the stability of an individual’s personal relationships, and even their status at work or school. By examining multiple different factors rather than relying solely on a medical “lens,” treatment providers are better able to support their clients as they recover from a dual diagnosis.

Recognizing The Symptoms of a Dual Diagnosis

Dual diagnosis can include multiple forms of substance abuse as well as mental illness. As a result, there is no definitive list of possible signs and symptoms for someone with co-occurring disorders. However, there are some common signs that may indicate when someone might be at risk.

For example, day-to-day functioning can be challenging for someone who has a dual diagnosis that has been left untreated. They may find it hard to maintain a job or a functioning relationship. They may also have legal problems or difficulty with their finances. Other signs of a potential dual diagnosis to watch for include:

• Signs of anxiety, depression, or bipolar disorder before the development of any addiction.
• Other mental issues become worse without the use of drugs or alcohol.
• Individuals cast aside old friends or alienate loved ones.
• Emotions shift from periods of depression to periods of extreme high.
• Drugs or alcohol provide a sense of control
• Quitting drugs, alcohol, or smoking has been unsuccessful despite past attempts.
• Concentrating is hard.
• Trying to stop using drugs or alcohol leads to depression.
• The individual has a family history of addiction or mental illness.
• Erratic behavior, sleeplessness, and irritability are common.

Common Signs of Substance Abuse

Additionally, if you are worried that a friend or loved one is dealing with substance abuse, these are some signs to look for:

• Dilated pupils or pinpointed eyes
• Valuables seem to vanish or they chronically lack money
• Erratic behavior
• Lack of personal hygiene
• Alienating friends and family
• Needles, lighters, medicine bottles, and other drug paraphernalia in the house
• Needle marks or unusual bruising

Common Signs of Mental Illness

Some of the signs that could indicate mental illness include:

• Family history of mental illness
• Depression symptoms such as hopelessness, despair, or worthlessness
• Delusions or hallucinations
• The compulsive need to do things a certain way in order to relieve anxiety
• Mood swings that prevent normal standards of living
• Dramatic changes in energy levels or moods
• Reckless behavior and anger

The Challenges Behind Dual Diagnosis

Acceptance of substance abuse as a medical condition has grown, but there is still a stigma that accompanies an addiction diagnosis. It is important for the family and friends of someone with a dual diagnosis to be supportive and helpful during their loved one’s journey to better mental and physical health. The road to recovery may not always be straightforward, so it is important to be prepared for challenges and even setbacks along the way.

Unfortunately, many of these challenges prevent individuals from getting the help and support they need. A 2016 national survey conducted by SAMHSA found that more than half (52%) of people with a co-occurring diagnosis did not receive any treatment.

Let’s explore some of the challenges common among dual diagnoses:

1. Making an accurate diagnosis

• A combination of mental health and addiction issues can make it challenging for someone to receive an accurate diagnosis. Determining if someone has a substance abuse disorder as well as a serious mental illness is complicated by the overlap of certain symptoms, including insomnia, anxiety, depression, mania, and psychosis. These symptoms can be found in both people with substance abuse issues and those without, so it is important that an individual receives a careful clinical assessment to determine what is causing their symptoms.
• Some people might not share the extent of their substance abuse. When this happens, the individual may receive inappropriate treatment or have unrealistic expectations about their health, both of which can hinder true recovery.
• That’s why it is extremely important to turn to a reputable treatment provider when managing a dual diagnosis. Experienced treatment providers may require a period of observation, the completion of a detox program, and a period of sobriety before making an official diagnosis. During the initial sober period, treatment providers may also temporarily discontinue or review any medications being taken for psychiatric issues for a more accurate picture of their overall health.

2. Challenges with medication

• The correct use of medication is essential in managing a dual diagnosis. Both underutilization and overutilization of medications can hinder a person’s handling of their substance abuse and mental illness. It can be a challenge to determine the correct medications while being mindful of the potential for abusing prescribed medications like sleep aids, muscle relaxants, antidepressants, and antipsychotics. Any prescribed medications also need to be offered along with a multidisciplinary and integrated plan of treatment. Some treatment programs have a medical director who is licensed to prescribe medications, while others work hand-in-hand with an individual’s mental health provider to ensure they are taking the appropriate medication.

3. Physical and emotional challenges

• Another potential issue when it comes to dual diagnosis is the neglect of other aspects of a person’s health.
• For example, a struggle with substance abuse can impact a person’s physical well-being, increasing their chances of developing heart and blood disease, stroke, cancer, lung disease, Hepatitis B and C, and HIV/AIDS. There are also physical consequences that often occur alongside mental disorders, such as nutritional and metabolic disease, muscle and bone disease, and sexual dysfunction.
• Emotional issues can arise as well, especially when left untreated. Individuals may suffer from feelings of guilt and isolation. They may be distanced or estranged from family and friends. They may have increased feelings of stress, anxiety, or depression, as well as more thoughts of suicide. The potential emotional effects may vary depending on the type of mental illness and substance abuse that makes up each person’s dual diagnosis.

Integrated Treatment Model for Dual Diagnosis

Leading treatment centers now understand that integrated intervention — or treating both issues together — is a more effective approach to help an individual recover from dual diagnosis.

Because a dual diagnosis is different for each person, treatment must also take into account each individual’s unique circumstances. Some of the most common treatments that many doctors and therapists may use include medical detoxification, inpatient rehabilitation, partial hospitalization, intensive outpatient treatment, psychotherapy, medications, support groups, and aftercare.

Medical Detoxification

The first step in dealing with a dual diagnosis is to stop using drugs or alcohol. Detoxing at a rehab facility provides access to trained staff that can help in handling any withdrawal symptoms. Reputable detox programs require medical personnel to monitor the individual to help them stay safe and address any complications that may arise during the detox period. Ask your treatment program for a recommendation for a trusted medically supervised detox program if they don’t offer the service themselves.

Evaluation and Treatment Plan

The next step is an evaluation by professionals trained in providing the therapy, support, and medication necessary to treat substance use disorders as well as their underlying causes. Whether the individual chooses to enroll in a residential or outpatient recovery program, they should have a unique treatment plan created for them that includes:

• Psychotherapy: Therapy is a crucial component of treating a dual diagnosis. Cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT) have been proven particularly effective. Both of these forms of behavioral therapy have been shown to help individuals change unproductive patterns of thinking, manage overwhelming emotions and learn how to cope with addictive triggers in order to avoid relapse.
• Medications: Depending on the form of mental illness, there may be medications available that can help manage some of an individual’s symptoms. Additionally, medications can help lessen withdrawal symptoms from certain substances. Along with therapy, the goal of medications is to help empower the individual to manage and cope with their dual diagnosis. In many cases, treatment centers are able to use behavioral therapy and peer support with minimal medication intervention.
• Support Groups and Aftercare: Maintaining sobriety and strong mental health after dual diagnosis treatment also requires help from others. Forms of aftercare such as supportive housing options and support groups like Alcoholics Anonymous and Narcotics Anonymous can be crucial in addressing any ongoing needs while maintaining the person’s well-being.

Unfortunately, there is no quick fix for a dual diagnosis. Treatment does take time, but because of the individualized nature of this issue, each person’s treatment plan will proceed at a pace that is right for them.

Read more about dual diagnosis and how to find help if you or a loved one are dealing with addiction and mental illness at the full guide ‘Dual Diagnosis Treatment’