Dual Diagnosis (Co-Occurring Disorders)

This article provides a comprehensive overview of the dual diagnosis, including the main features and symptoms, established risk factors, and professional treatment options.

Key Takeaways:

• A dual diagnosis refers to a diagnosis of both a mental health disorder and substance use disorder.

• Mental health problems can increase the risk of substance use issues, and vice versa. Having both conditions may lead to more significant impairments in mental well-being and life functioning compared to either alone.

• The most effective dual diagnosis treatment involves an integrated approach that addresses both disorders simultaneously. Common treatments include psychotherapy, medication, and support groups.

Understanding Dual Diagnosis

The term “dual diagnosis” is used to describe someone who is diagnosed with both a mental health disorder and a substance use disorder (SUD). Examples of mental health disorders include anxiety, depression, post-traumatic stress disorder (PTSD), and schizophrenia, while examples of SUDs include disordered use of alcohol, nicotine, or illicit drugs. ^[1]

A dual diagnosis falls underneath the broader category of mental health comorbidities, also referred to as co-occurring disorders, which is when someone has two or more mental health disorders simultaneously. ^[1]

How Common is It?

Having a dual diagnosis is relatively common. In the United States, among the 70 million adults that had either an SUD or mental health disorder, 17 million had a dual diagnosis. ^[2]

Other research shows that 35% of adults over 18 who have a mental health disorder also have a SUD. Furthermore, nearly half of people with a SUD will also have a mental health disorder at some point in their life, and vice versa. ^{[3] [4]}

The Link Between Substance Use and Mental Health

There are several links between substance use and mental health. Overall, it is a bidirectional relationship, in that substance use problems can increase the risk for poor mental health, and vice versa.

Both adolescents and adults with mental health disorders are much more likely to use alcohol, tobacco, illicit drugs, and opioids compared to those without a mental health condition. In addition, anxiety, depression, post-traumatic stress disorder (PTSD) and other mental health conditions increase the risk of developing SUDs. ^{[1] [4]}

Individuals with mental health disorders are responsible for 38% of all alcohol use, 44% of cocaine use, and over 50% of all opioid prescriptions in the United States. ^[5]

There are several factors at play. Firstly, individuals with anxiety, depression, and other mental health disorders may turn to substances to feel better temporarily and relieve stress. Adding to this, mental health disorders may alter the brain in such a way that increases addictive-like tendencies. ^[3]

In addition, SUDs may alter the brain in such a way that increases the likelihood of experiencing poorer mental health. For example, SUDs can lead to brain changes that worsen symptoms of schizophrenia, bipolar disorder, anxiety, and impulse-control disorders. ^[4]

Which Comes First?

It is very difficult to determine if SUDs caused mental health disorders, or vice versa. In fact, sometimes it’s impossible to tell.

Moreover, just because two things occur at the same time, does not mean one directly caused the other. In most cases, there are underlying risk factors, coupled with external factors and personal choices, that increase the risk for SUDs and mental health disorders simultaneously. ^{[1] [3]}

Symptoms of Dual Diagnosis

Someone who has a dual diagnosis will exhibit symptoms of a mental health disorder and symptoms related to their SUD. Thus, the symptoms will depend on which exact disorders are involved. In addition, it's important to understand that people can also have multiple mental health disorders and SUDs at the same time. ^{[3] [4]}

In general, symptoms of SUDs include: ^{[2] [3]}

• Using a larger amount of a substance or taking it for a longer time than expected or planned

• Unsuccessful attempts to stop or reduce substance use

• Spending a lot of time or effort to obtain or use the substance

• Strong cravings, urges, or desires for substance use

• Continuing to use a substance despite negative consequences, such as:

• Decreased school or work performance

• Interpersonal or social issues

• Behavior changes

• Giving up important life activities

• Using a substance in physically dangerous situations

• Worsened physical or mental health

• A need for increased amounts of a substance to reach the desired effect

• Withdrawal effects when the substance is stopped or reduced

Symptoms of mental health disorders may include:

• Significant mood changes

• Trouble focusing or concentrating

• Agitation or irritability

• Persistent sadness or hopelessness

• Severe worry, fear, or anxiety

• Isolating oneself from others and activities

• Difficulty functioning at school, work, or in life in general

• Trouble sleeping

• Changes in eating patterns

• Suicidal thoughts

• Significant changes in behavior

Risk Factors

Several risk factors seem to underlie or contribute to the development of SUDs and mental health disorders. These risk factors include: ^{[1] [4] [6]}

• Genetics

• Stress

• Trauma

• Childhood trauma/abuse

• Psychological and personality traits

• Adverse social environments

A variety of different genes contribute to the risk of developing mental health disorders and SUDs. In addition, both types of disorders can run in families, so having a family history also increases risk. ^[3]

As listed above, stress, trauma, and adverse social environments are some of the key environmental factors that increase the risk of a dual diagnosis. Childhood trauma, such as abuse and neglect, is a particularly significant risk factor. ^[4]

Diagnosis

A dual diagnosis is typically made by a mental health professional, such as a psychologist or psychiatrist. In some cases, your doctor may be able to diagnose you if the symptoms are relatively straightforward.

You won’t ever receive the diagnosis of “dual diagnosis”. Instead you’ll receive a separate diagnosis for a specific mental health condition and for a specific SUD. ^[3]

Tests and Assessments

A variety of tests and assessments may be used to determine a dual diagnosis. It is a comprehensive process, which is particularly important, given that symptoms of mental health disorders can overlap with SUDs. ^[3]

Examples of tests and assessments your doctor or mental health professional may implement include: ^{[3] [6]}

• Screening tools

• Mental health questionnaires

• Clinical interviews

• Behavioral observations

• Any relevant medical tests or physical exams (e.g. blood work, urine sampling)

Treatment Options

There are several types of treatment options for a dual diagnosis. Common treatment options include:

• Psychotherapy

• Medication

• Support groups

• In-patient care

Rather than treating each disorder separately, evidence shows that it’s best to use an integrated approach to treat both disorders simultaneously. This leads to the best outcomes, and is also more convenient for the patient. ^[7]

Psychotherapy

Psychotherapy is a form of talk therapy that helps to address any maladaptive thoughts, behaviors, and emotions that may be contributing to one’s current issues. It also commonly involves helpful techniques, such as stress management, emotional regulation, and goal-setting. ^{[1] [2] [5]}

Examples of psychotherapy include: ^{[1] [3] [5]}

• Cognitive-behavioral therapy (CBT)

• Motivational interviewing

• Dialectical behavior therapy

Medication

Certain medications, such as antidepressants, anti-anxiety drugs, or mood stabilizers, may be used to address the symptoms of mental health disorders. Other medications may be used to help with addiction and other related issues with substance use. Some drugs may be able to help both conditions simultaneously. ^{[1] [3]}

Support Groups

Support groups can be an important part of a dual diagnosis treatment plan because they provide individuals with emotional support and social connection. Support groups also often go over tips and strategies to deal with common symptoms and issues in everyday life when living with a dual diagnosis. ^{[1] [3] [8]}

In-Patient Care

In-patient care may be needed for more severe instances of concurrent mental health issues and SUDs. This form of treatment involves medication, therapy, support, and other treatments at a dedicated treatment center. ^{[3] [5]}

Managing a Dual Diagnosis

Managing a dual diagnosis can be challenging, but there are many things you can do to make it easier. Professional treatment should always be the priority, but there are also other things you can do alongside treatment to help manage your co-occurring mental health disorder and substance problems. This includes:

• Practicing regular healthy habits (e.g. healthy diet, exercise, adequate sleep)

• Stress management activities (e.g. meditation, deep breathing, yoga, sauna)

• Journaling

• Setting relevant goals, such as for work, school, or daily life

• Keep your days structured and organized

• Calendars, timers, note cards, planners, and other tools can be helpful

• Healthy social interactions

• Engaging in hobbies and enjoyable activities

In addition, make sure to keep up with your treatment plan by taking any medications as prescribed, and to be consistent with therapy. Involving family and/or friends can help you to stay on top of treatment and to provide reassurance and support.

Long-Term Recovery

Recovery from a dual diagnosis is usually a long-term process that requires significant time, commitment, and effort. In order to achieve long-term recovery, social support is essential. This can be achieved through consistent support from family or friends, as well as through dedicated self-help or support groups, such as Alcoholics Anonymous and Narcotics Anonymous. ^[8]

In addition, it’s important to seek assistance for any factors that may be contributing to your mental health and/or substance use issues, such as stigma, low self-esteem, lower education, or limited vocational abilities. There are many services out there to help address these concerns, which can lead to improved mental well-being and greater functioning in general. ^[8]

The more consistent you are with professional treatment and daily self-management strategies, the more likely it is that you will succeed.

Takeaway

Having a dual diagnosis can make it difficult to function, and you may feel overwhelmed. However, it’s important to remember that you’re not alone, and professional treatment is available for your mental health condition and substance use problems. With the right treatment and support, you may be able to overcome these issues and experience a fuller, healthier life.