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Substance abuse disorders are often accompanied by some sort of mental illness. Whether the mental illness is mild or severe, and led to drug use or developed because of it, the simultaneous presence of both conditions requires a specialized treatment approach that properly addresses the deeply intertwined relationship one has to the other. This circumstance is known as dual diagnosis or co-occurring disorders. 

This concept came about in the 1980s once medical professionals realized how often substance abuse occurred with mental illness. Further, they realized that a different kind of addiction approach would be needed as trying to resolve addiction in isolation fails to get to the root of the complex physical and psychological aspects of this condition. 

 

Dual Diagnosis: The Relationship Between Drug Use and Mental Illness

A mental health disorder is defined as a “diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities.” This is nearly identical to the definition of addiction, which is when the “recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.” The ways in which both conditions manifest themselves revolve around the disruption of daily life and responsibilities.

But more than simply having similarly disruptive effects on an individual’s life, there is a concerning correlation between mental illness and substance abuse. Numerous studies have shown that individuals who suffer from a mental illness are not only more likely to turn to drug use, but are more prone to becoming addicted to those substances, and more likely to relapse after treatment. 

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), there are more than 43.6 million Americans aged 18 and up who have some form of mental illness. Of these individuals, 7.9 million had both a mental health and substance use disorder, otherwise known as co-occurring disorders. There is no distinction made as to whether drug addiction or mental illness occurred first. To addiction professionals, all that matters is that both are addressed simultaneously.

 

Examples of Co-Occurring Disorders

A substance use disorder is diagnosed based on a set of symptoms that indicate the substance use is interfering with daily functionality and causing harmful effects physically, mentally, or in other areas of a person’s life. People with severe mental illness have among the highest rates of co-occurring substance use disorders. These types of illnesses include:

  • Major depression
  • Bipolar disorder
  • Post-traumatic stress disorder
  • Panic disorder
  • Social anxiety
  • Generalized anxiety disorder
  • Obsessive-compulsive disorder
  • Schizophrenia
The first co-occurring disorder for alcohol dependency is technically not co-occurring at all, depending upon your point of view. There are some who do not consider alcohol to be a drug, whereas others believe drugs and alcohol to be on the same level. In any case, drug addiction and alcoholism frequently go hand-in-hand. Alcoholics can be beset by other co-occurring disorders as well. One of these is Korsakoff’s syndrome, which inhibits a person’s ability to create new memories. There are also basic mood disorders, such as anxiety and depression. Schizophrenia, mania, dementia, and bulimia have also shown correlations with alcohol dependency. To be fair, some of the studies on this are imperfect and have produced widely varying results. For instance, the correlation between alcoholism and bulimia is believed to rank at anywhere from 33% to 83%, which is a remarkably sizable range. However, while all of the above disorders show levels of comorbidity with alcoholism, one of the greatest is an antisocial personality disorder. While some believe that “antisocial” indicates a disinclination toward socialization, this is not quite the case. Antisocial personality disorder is actually characterized by an extreme disregard for social conventions. Those who suffer from ASPD may have trouble feeling sympathy for others and may engage in harmful or illegal behaviors. They may also show a penchant for frequent dishonesty. Alcoholism and antisocial behavior are so closely linked that alcoholism is actually one of the criteria for diagnosing ASPD. And this can be troublesome because the decreased inhibitions which accompany alcohol abuse can exacerbate the alcoholic’s antisocial tendencies.
Antisocial behavior disorder is also one of the primary co-occurring disorders for cocaine, although there are certainly several more. Depressive disorders and post-traumatic stress disorder are among them. In fact, the depression and antisocial tendencies of cocaine addicts can be so bad as to interfere with the addict’s susceptibility to psychiatric therapy and addiction recovery counseling. This is why it is absolutely paramount that these disorders be diagnosed early in recovery if the addict is to receive proper treatment. While the above issues are all troubling, anxiety disorders can actually be among the most prominent co-occurring disorders suffered by cocaine addicts. This certainly ties into the cocaine user’s susceptibility to disorders such as PTSD. In addition, those who suffer from cocaine dependency have been found to be at least three times more likely to experience panic attacks. Other anxiety-related issues, such as agoraphobia, have also been associated with cocaine usage (and substance abuse at large, for that matter). Bipolar disorder has also been associated with cocaine dependency. Studies have shown that those who seek therapy for cocaine addiction will often seek therapy for one or more of the above disorders as well. In much the same fashion as alcohol dependence may exacerbate the alcoholic’s antisocial behaviors, cocaine addiction may worsen any co-occurring disorders related to anxiety. Fortunately, this does not work the other way around. In other words, the comorbidity of anxiety disorders will not necessarily increase the severity of the user’s cocaine addiction. However, the co-occurring disorders of anxiety and cocaine dependency are likely to heap a great deal of stress upon the addict. For this reason, anxiety disorders must be targeted early on once the cocaine user has agreed to seek treatment for their addiction.
There is generally a link between the abuse of heroin and the abuse of Demerol, Oxycontin, and other opioids. As such, the major co-occurring disorders of these substances tend to exhibit some overlap. One of the major issues facing those who abuse these substances is depression. In fact, this problem is so great that in 2010, somewhere around 1600 fatal overdoses were discovered to have been successful suicide attempts rather than accidental deaths. And these were only the overdoses that were discovered and recorded. Accounting for failed suicide attempts by heroin and opiate users would be much more difficult. Depression is certainly one of the major co-occurring disorders related to heroin and opiate abuse, but PTSD is arguably a much greater concern. The link between PTSD and opiates has been assumed for quite some time. In the 1970s, it was discovered that many of the American soldiers sent to fight the Vietnam War were suffering from heroin dependency. And while their rates of use were much lower upon their return to the United States than the relapse rates of addicts who used domestically, there was still a correlation of 60-80% between Vietnam veterans who were treated for PTSD and those who were treated for substance dependency. Sufferers of PTSD are not exclusively limited to members of the armed forces. Any particularly traumatic event, such as physical or sexual abuse, can lead to this disorder. This can result in outbursts of rage and general aggression, anxiety, sleep disruption, nightmares, and flashbacks. These symptoms are especially bad when the sufferer is reminded of the trauma that led to the disorder, even when the reminder in question is a simple sensory stimulus. In addition to substance abuse, PTSD has its own list of co-occurring disorders, such as depression and ADD, as well as more psychosomatic issues such as chronic pain and high blood pressure.
There are many co-occurring disorders associated with methamphetamine abuse, some of which are experienced mostly during active addiction while others tend to surface during periods of withdrawal. During active addiction, meth users will often experience periods of hypomania and extreme sleeplessness. They also tend to suffer from severe psychosis, which can lead to hallucinations and paranoid delusions. Disruptions to the user’s circadian rhythms will often exacerbate some of these issues, and their delirium may become more severe during especially prolonged periods of insomnia. Depression and ADD may also be seen as co-occurring disorders, especially since many amphetamine-containing medications are prescribed to combat these very issues. Most of the co-occurring disorders listed above, with the exceptions of ADD and depression, are generally caused by the substance abuse itself. However, they can take such a toll on the user that many of these symptoms will continue for quite some time after the addict has stopped using. Withdrawal periods may also exacerbate such issues as depression, and insomnia will be replaced with narcolepsy-like crashes that cause the user to sleep more than usual. This particular withdrawal symptom is known as hypersomnia, and is one of the most common co-occurring disorders exhibited by meth users during periods of reduced substance use. As one might surmise, these frequent switches between periods of depression and periods of hypomania may also be associated with co-occurring disorders such as bipolar disorder and manic depression. Meth users often get caught in something resembling a negative feedback loop with these disorders. When their manic period subsides and they begin to feel depressed, they will increase their substance abuse and start the entire cycle all over again. This ranks mania and depression (or bipolar disorder/manic depression if such disorders are diagnosed) among the most important co-occurring disorders to address when treating patients who suffer from methamphetamine dependency.
Some people may not consider marijuana to be as extreme as some of the substances listed above, but it still carries its fair share of co-occurring disorders. In fact, one of the major mental illnesses that is often comorbid with marijuana dependency is schizophrenia. It has long been known that schizophrenia is often comorbid with substance dependency, to the extent that close to half of all schizophrenics have been found to abuse illicit substances. But in the case of marijuana, the link is so strong that it was once believed that imbibing marijuana at high levels might actually cause schizophrenia. It is now known that this is not true. Nonetheless, schizophrenia is still undeniably one of the most prominent co-occurring disorders associated with marijuana addiction. The same study that disproved the notion that marijuana use caused schizophrenia also examined two other co-occurring disorders: depression and bipolar disorder. Marijuana was not determined to be a cause of these disorders, but it was not fully ruled out, either. The most that could be determined for certain was that both depression and bipolar disorder tend to appear in the family histories of many cannabis users. While the use of cannabis was not determined to be a cause of bipolar disorder, it was discovered that many addicts who suffer from marijuana dependency tended to have longer and more severe affective episodes during prolonged periods of heavy use. They would also cycle between mood states with more rapid frequency. Psychiatric treatment was usually needed to lessen the rates of recurrence in these cycles. Although the two drugs are ostensibly nothing alike, this shows an interesting similarity between the co-occurring disorders associated with marijuana dependency and those which are associated with methamphetamine abuse.
 

Why Do Co-Occurring Disorders Happen?

There are several reasons why mental illness so often coincides with drug abuse and addiction. Most of them are rooted in the fact that the mechanisms that result in either disorder can be caused or exacerbated by the other. There is often an overlap between the neurological conditions created by drug use and the ones that result in mental illness which is why it’s very possible for one to cause the other and vice versa. 

 

How Drug Use Can Cause Mental Illness

Substances abuse can trigger symptoms of an underlying mental health disorder or, if they already exist, make them worse. In fact, anxiety, depression, and paranoia are common psychological side effects of drug use. Why? These and many other mental health disorders are the result of some sort of neurological imbalance. Drug use can cause these imbalances in an otherwise mentally healthy individual, and with prolonged use, result in permanent changes to the brain structure that can leave a person with too little (or too much) dopamine in their body. In severe cases, chronic substance abuse can result in schizophrenia and psychosis.

 

How Mental Illness Can Cause Drug Addiction 

The imbalances in brain chemistry that cause mental health disorders can make a person predisposed to turning to substance abuse; getting addicted quickly and more intensely. Mental illness is often a result of a neurological imbalance, and depending on the responsible neurotransmitter, can result in lower stress tolerance, impaired judgment, or lack of impulse control. Undiagnosed mental illness also poses a prominent cause in addiction, as these individuals may struggle to deal with their emotions and as such, turn to drugs to self-medicate. 

All of these factors can make a person more likely to turn to experimental or recreational drug use. But because these individuals already have a neurological imbalance, the effects of drug use are even more drastic, which is why they are particularly prone to addiction. According to SAMHSA, around 21.5 million Americans ages 12 and above had a substance use disorder in 2014. Of those people, SAMHSA estimated 2.6 million had a problem with both drugs and alcohol. 4.5 million reportedly had problems with just drugs, and 14.4 million had a problem only with alcohol.

 

Dual Diagnosis Addiction Treatment

Dual diagnosis is a specialized type of addiction treatment designed to help individuals suffering from drug addiction and mental illness disorders at the same time. Although it can be impossible to determine which disorder is causing the other, the presence of both makes it extremely difficult (and often, ineffective), to try and treat drug addiction on its own. If someone has a dual diagnosis, it’s important that their mental illness be diagnosed and treated at the same time.

 

Types of Treatment

Standard means of rehabilitation primarily rely on cognitive behavioral therapy, something that can’t undo mental illness on its own. With this type of addiction being rooted in neurological causes, successful treatment relies on a number of different types of psychotherapy in addition to pharmacotherapy to address how both mental illness and addiction can affect a person’s behavioral tendencies.

 

Cognitive Behavioral Therapy

A common fixture in addiction treatment centers, cognitive behavior therapy (also referred to as CBT) helps individuals break negative patterns of behavior tied to drug use. This involves identifying triggers, dispelling negative thought patterns and beliefs, and instilling healthier new coping mechanisms. This standard type of treatment is vital for relapse prevention.

 

Dialectic Behavioral Therapy

Also known as DBT, dialectical behavioral therapy was initially developed as a means for treating patients with mental illness that had chronic suicidal tendencies. Unlike cognitive behavior therapy which focuses on change and can result in resistance from patients, DBT focuses on fostering feelings of acceptance and validation, primarily through acknowledging parts of themselves or past actions that they do not like. Further, it aims to instill in patients a means to handle the extreme emotions that individuals with mental illness are often subject to.

 

Integrated Group Therapy

A relatively new method of treatment, integrated group therapy (IGT) is based on the cognitive-behavioral therapy model for relapse prevention. Whereas normal group therapy sessions may only focus on topics specific to drug addiction, IGT sessions almost exclusively deal with topics that are relevant to both these disorders. The philosophy behind this treatment method is that the same types of behaviors and thoughts that can be effective in treating addiction are also helpful in dealing with mental disorders (and vice versa). 

Many individuals who suffer from drug addiction or alcoholism have co-occurring mental health disorders. People with mental health disorders are more likely than other population groups to also have substance use disorders. Unfortunately, diagnosing these co-occurring disorders can be challenging because of how complex the issues are.

 

Individual Psychotherapy

Psychotherapy, better known as talk therapy, is a form of long-term treatment that focuses on diagnosing, treating, and monitoring a person’s mental state. Sessions are conducted by psychiatrists who are medical doctors who are equally concerned with mental health problems as a person’s physical conditions (weight, blood pressure, liver function, etc.) and how medications are affecting the body. Further, psychiatrists are licensed to write prescriptions to help manage the symptoms of a mental disorder. Cognitive behavioral therapy and dialectic behavioral therapy are two of several types of psychotherapy.

 

What Is a Dual Diagnosis Program Like?

When someone is believed to demonstrate symptoms of a psychiatric condition along with a substance use disorder, addiction treatment facilities will arrange for the specialized approach of a dual diagnosis program. First there will be an in-depth evaluation to help determine a diagnosis. Afterward, the information that’s derived from an initial evaluation and intake assessment can then be used to create a treatment plan.  that deals with the psychiatric disorder and substance abuse simultaneously.

Two scenarios may occur when someone initially seeks treatment for addiction. In one scenario, the patient may already know they have a psychiatric disorder. In the other scenario, going to addiction treatment may be the first time a person ever receives a mental health diagnosis. Some of the elements that might be used when providing treatment for co-occurring disorders include:

  • Individual therapy or counseling is integral to dual diagnosis treatment. It can specifically address not only the issues surrounding someone’s substance abuse but also the symptoms they experience as a result of their psychiatric disorder.
  • Behavioral therapy, such as cognitive-behavioral therapy is a way to help someone recognize their own thoughts and attitudes. As a result of that recognition, begin to change their behaviors.
  • When necessary, medication management may be part of dual diagnosis treatment. Medication can help treat symptoms of the psychiatric disorder, which can promote better outcomes for the addiction treatment program.
  • Group therapy is a very important part of dual diagnosis treatment for people with addiction disorders and mental health disorders.
  • Family therapy can help the loved ones of someone struggling with co-occurring disorders to better understand what is happening.
  • Most dual diagnosis treatment programs will begin laying a foundation for 12-step programs, something a person can participate in long after the initial addiction treatment ends.
  • Holistic treatment approaches are often utilized in dual diagnosis programs because they address the physical, psychological and spiritual needs of the patient.

 

Why Choose A Florida Dual Diagnosis Treatment Center

If both addiction treatment and mental health services aren’t provided, it’s much more likely someone will leave treatment early and relapse. They are also at a higher risk of relapsing after completing a treatment program. Dual diagnosis treatment for co-occurring disorders can also address and proactively deal with possible barriers to treatment.

For example, someone with a psychiatric disorder may demonstrate volatility in their emotions. This can deter them from staying in treatment long enough, or engaging with treatment. With a dual diagnosis approach, this can be addressed and dealt with in a way that’s going to help the patient continue with their treatment.

At Amethyst Recovery Center, we complete a thorough assessment of the individual prior to entering any level of care for treatment. Occasionally we will find that prior to entering our program, clients may have been improperly medicated for one or more co-occurring disorders. Sometimes this might mean they are over-medicated for issues like anxiety or ADHD which can increase the likelihood of substance abuse.

The purpose of our dual diagnosis addiction program is to guide our clients through the recovery process while developing goals for the immediate future following treatment. When necessary, we may refer clients to an outside clinician in their area to continue psychiatric treatment after they have been discharged from our program.

 

Resources

https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Dual-Diagnosis

https://www.samhsa.gov/disorders

https://www.samhsa.gov/disorders/mental

https://www.samhsa.gov/disorders/substance-use

https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Dual-Diagnosis

https://www.psychologytoday.com/us/blog/recovery-road/201804/mental-illness-and-substance-abuse

https://psycnet.apa.org/fulltext/1992-05844-001.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2200799/

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