Addiction and mental illness often co-occur, and when this happens, it’s known as a dual diagnosis or co-occurring disorder treatment. Dual diagnosis is very common, and it requires specialized treatment that addresses both the addiction and the mental illness at the same time. Here’s what you should know about dual diagnosis, including how it develops and how it’s diagnosed and treated.
Dual Diagnosis: Mental Illness Defined
Mental illness causes changes in mood, emotion, thinking, or behavior—or a combination of these. Mental illness can interfere with healthy social functioning, and it can cause problems in relationships and elsewhere. It reduces feelings of wellness and can even lead to physical illnesses.
Around 20 percent of Americans have a mental illness, according to the American Psychiatric Association1 . Anxiety and depression are the most common mental illnesses. Anxiety disorders like social anxiety or panic disorder affect nearly 40 million American adults, and another 15 million are suffering from major depression at any given time.
Mental illness is treatable, but many people resist treatment due to the persistent stigma of mental illness. The best way to treat mental illness is through a combination of medication and counseling.
Dual Diagnosis: Substance Use Disorders Defined
Substance abuse, addiction, and dependence are diagnosed under the umbrella of a “substance use disorder,” or SUD. These terms are still commonly used, often interchangeably, but substance abuse, addiction, and dependence are not the same things.
Substance abuse is the use of drugs or alcohol in a problematic way. Drug and alcohol abuse can cause problems related to your relationships, health, finances, or the law, and substance abuse often leads to high-risk situations. Binge drinking is the most common form of substance abuse and occurs when you drink enough alcohol over the course of two hours to bring your blood alcohol content up to .08 percent. One in six Americans binge-drink around once a week, according to the Centers for Disease Control.
Substance abuse is not addiction, although it can lead to addiction, which is characterized by compulsive drug or alcohol abuse despite the negative consequences it causes. People who are addicted will continue to abuse drugs or alcohol even though it’s causing serious problems in their life. They may want or try to quit but find that they can’t.
Addiction is the result of changes in the brain’s structures and chemical functions related to reward, memory, learning, and motivation. Brain regions begin to communicate in a way that leads the brain to equate liking drugs or alcohol with wanting them, and the result is intense cravings and compulsive drug-seeking behaviors. Addiction leads to dysfunctional thought and behavior patterns that further perpetuate the addiction and cause even more problems.
Dependence is a physical reliance on drugs or alcohol. It’s characterized by withdrawal symptoms that occur when you quit using. Dependence develops as the brain attempts to adjust its chemical function to compensate for the presence of drugs or alcohol. This leads to tolerance, which means you need increasingly larger doses of drugs or alcohol to get the same effects a smaller dose once produced. However, the more you use, the more the brain changes as it tries to maintain normal function.
At some point, brain function may shift so that the brain now operates more comfortably when the substance is present. Then, when you suddenly stop using, the normal chemical function of the brain rebounds, and this swift shift in neurotransmitter activity causes physical withdrawal symptoms, which can be excruciating.
Why Mental Illness & SUDs Co-Occur in a Dual Diagnosis
Dual diagnosis is very common. According to the National Alliance on Mental Illness, around one-third of people who have any type of mental illness—and half of those with a serious mental illness, such as bipolar disorder or schizophrenia—also have a substance use disorder2 . Conversely, around one-third of people who abuse alcohol and more than half of those who abuse drugs also have a mental illness.
The National Institute on Drug Abuse offers three scenarios that help explain the high prevalence of dual diagnosis3:
- The changes in brain function caused by drug abuse can lead to mental illness, or it can worsen an existing mental illness.
- People with a mental illness often self-medicate their symptoms with drugs or alcohol, such as using alcohol to reduce anxiety or using drugs in an attempt to feel happy.
- Substance use disorders and mental illnesses have overlapping factors that leave some people at a higher risk for co-occurring disorders.
The overlapping factors that can cause a mental illness and an SUD to co-occur include:
- Overlapping genetic risks: Several genes are linked to both SUDs and mental illness. Some of these genetic factors have a direct influence on developing an SUD, such as metabolism, while others have an indirect influence, such as personality traits that lead to engaging in high-risk behaviors.
- Involvement in similar brain regions: Some brain regions are involved in both substance use disorders and mental illness. The dopamine system, for example, plays a key role in both addiction and depression.
- Environment: Environmental factors like stress or family dysfunction can lead to substance abuse as a coping mechanism, and they can also cause mental illnesses like anxiety or depression.
Mental Illnesses Commonly Dual Diagnosed with an SUD
While any mental illness can co-occur with a substance use disorder, some occur more frequently than others, including:
- Anxiety: People who have anxiety often self-medicate the unpleasant symptoms, such as sleep problems and feelings of doom, with drugs or alcohol.
- Depression: Major depression and bipolar disorder are associated with a higher risk of substance abuse. According to a study published in the journal Psychiatric Clinics of North America, around half of all people with bipolar disorder have a history of addiction4 .
- Obsessive-compulsive disorder (OCD): OCD, characterized by repetitive thoughts and behaviors, can lead to substance abuse in an attempt to relieve symptoms like unwanted, intrusive thoughts and compulsive repetitive actions.
- Post-traumatic stress disorder (PTSD): PTSD often occurs after experiencing a trauma, such as intense violence or sexual abuse. An article in the journal Alcohol Research and Health points out that 40 percent of people seeking inpatient treatment for an SUD have PTSD, and over half of combat veterans with PTSD develop an alcohol use disorder later on5 .
- Eating disorders: According to an article in the journal Social Work, up to half of all people who have an eating disorder abuse drugs or alcohol, compared to nine percent of the general population6 . People with eating disorders may engage in substance abuse in order to cope with negative emotions, suppress the appetite, or compensate for low self-esteem.
Diagnosing Co-Occurring Disorders: Integrated Screening Is Key
Due to the high prevalence of dual diagnosis, integrated screening is widely used in both mental health care settings and SUD treatment settings. People seeking treatment for mental illness are screened for a substance use disorder, and vice versa.
During medical detox, which is the first step of treatment for a substance use disorder, a variety of assessments are given to determine whether a mental illness is present and to try to determine whether the mental illness was caused by—or made worse by—the addiction or if it pre-dates the substance abuse. This information helps guide the treatment plan.
Integrated Treatment Is Essential for Dual Diagnosis Recovery
Treating just one disorder in a dual diagnosis will be largely ineffective for recovery from both. Successful recovery from both disorders requires integrated treatment. This involves treating the substance use disorder in the context of the mental illness and vice versa.
Treating both disorders at the same time, each in the context of the other, offers far better treatment outcomes, including:
- Reduced substance abuse
- Improved mental illness symptoms
- Increased stability at home
- Fewer legal problems
- A higher quality of life
Dual diagnosis treatment is a collaboration between the individual and the treatment teams. Fully integrated treatment involves:
- A single program that treats both disorders
- The same treatment providers treating both disorders
- An emphasis on a long-term recovery perspective
- A slow treatment pace
- An emphasis on trust and understanding
How Dual Diagnosis Treatment Works
A high-quality dual diagnosis treatment program will address issues of body, mind, and spirit. This holistic approach involves conventional and complementary therapies that address all a person’s multiple needs and issues for whole-person healing.
A range of therapies are used to address co-occurring disorders:
- Traditional therapies, such as cognitive-behavioral therapy, family therapy, and psychoeducational and skills classes.
- Complementary therapies, such as art therapy, restorative yoga, and mindfulness meditation.
- Pharmacotherapy, or the use of medications to treat symptoms of mental illness or reduce drug or alcohol cravings.
This three-pronged approach to treatment helps individuals:
- Identify unhelpful patterns of thought and behavior and replace them with healthier ways of thinking and behaving.
- Address the underlying issues that led to the substance abuse and mental illness, which often includes chronic stress or a history of trauma.
- Develop coping skills for dealing with mental illness symptoms, stress, cravings, negative emotions, and other powerful relapse triggers.
- Learn about substance use disorders and mental illness, including how they develop, how they’re treated, and how long-term recovery is achieved.
- Repair damaged relationships and explore family and household issues.
- Address a range of needs, including the need for legal, educational, vocational, or housing assistance.
- Find hobbies and engage in purposeful activities that bring meaning and enjoyment to life.
- Learn to relax and have fun without drugs or alcohol.
Dual diagnosis treatment helps people improve their lives in many areas for increased happiness and wellbeing, which further promotes long-term recovery.
Anyone Can Recover
Recovery is hard work, but with professional help, many people overcome even a severe co-occurring disorder and go on to enjoy a productive, fulfilling life. Dual diagnosis treatment works for most people who engage fully with their treatment plan and stay in treatment for an adequate period of time -according to the National Institute on Drug Abuse, anything less than 90 days is of limited effectiveness 7 .
Treatment works, and it can work for you, too. Treatment helps restore function to your life and relationships, and it can lead to authentic happiness and wellbeing for the long-haul.
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