Co-Occurring & Dual Diagnosis Treatment Guide
What is A Co-Occurring Disorder?Someone with substance abuse disorder (drugs or alcohol) and mental illness (depression, PTSD, anxiety, OCD, etc.), the diagnosis is called a co-occurring disorder. Any combination of mental health disorders and substance abuse or addiction qualifies for this diagnosis (sometimes referred to as a dual diagnosis), such as alcoholism and depression, anorexia and cocaine dependence, post-traumatic stress disorder and heroin addiction, prescription drug dependence and anxiety, and more.
Though the symptoms of one disorder may predate the other, both disorders tend to exacerbate one another, making it impossible to extricate the symptoms caused by one disorder from the other. For example, those who attempt to escape symptoms of depression associated with a mood or personality disorder by taking prescription painkillers or shooting heroin will quickly find that though this may be effective the first few times.
In addition to the symptoms of depression, they will soon be struggling with:
- Cravings for their drug of choice
- A tolerance to their drug of choice, requiring higher and higher doses
- Increased episodes of mental health symptoms
- More intensive or longer-lasting mental health symptoms
- Experience of withdrawal symptoms
What Comes First: Addiction or Mental Illness?
All people are different when it comes to their experience with addiction and mental illness. Some begin to experience mental health issues during childhood or adolescence and experiment with drugs and alcohol soon after, developing both an addiction problem and a serious mental illness at the same time.
Others may seek out drugs and alcohol in an attempt to “self-medicate” a mental health issue that develops in early adulthood or that develops out of an injury or trauma later in life. Still others may first develop an addiction problem that grows so severe that it causes mental health issues or triggers the onset of symptoms that may otherwise have remained dormant.
What Is Addiction?
Addiction is defined as both a physical dependence and a psychological dependence upon a drug or multiple drugs, including alcohol. Physical dependence is characterized by a tolerance to the drug of choice (e.g., needing an increasingly larger dose in order to experience the desired effect), and psychological dependence is defined by cravings for the drug or obsessing over getting and staying high.
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), substance dependence is a single disorder that is measured on a spectrum from mild to severe and classified according to the substance of choice, with the exclusion of caffeine, which cannot be the subject of a substance abuse/addiction disorder diagnosis. For example, someone struggling with an alcohol problem may be diagnosed with alcohol abuse disorder or alcoholism depending upon the severity.
The diagnostic criteria for almost all substance abuse disorders are the same, according to the DSM-5. There are 11 symptoms that can signify a substance use disorder, and in order to be diagnosed with a mild drug abuse disorder, the person must exhibit two or three of these symptoms.
The National Alliance on Mental Illness (NAMI) reports that the 11 symptoms that characterize a substance use disorder include a pattern of substance abuse that leads to:
- An inability to manage obligations at work or at home (e.g., unable to care for children and other dependents, showing
up late to work or school, repeatedly missing work or school, etc.)
- Repeated use of drugs or alcohol in circumstances where it becomes physically dangerous (e.g., driving while under
- Ongoing interpersonal issue caused by the effects of chronic drug and alcohol use (e.g., fights with a significant
other due to behaviors under the influence)
- Tolerance for the drug of choice defined by either the need for higher and higher doses in order to feel the desired
effects of the drug or decreased effects with the same dose
- Withdrawal symptoms when without the drug of choice or a substance that is similar in effect
- Taking more of the drug than is intended either in a single use session or in a certain period of time
- An inability to stop using the substance of choice or to cut down on use
- Spending a large amount of time seeking the drug of choice, being high or drunk, or recovering from use of the drug
- Avoiding family activities, social events, or former hobbies due to substance use
- Continued use of drugs and alcohol despite the realization that the behavior is causing psychological, physical, and/or
- Cravings for the drug of choice
What Is a Mental Illness?
DSM-5 is the industry standard in the US for identifying the characteristics of any mental health disorder. For each mental health disorder, DSM-5 offers the diagnostic criteria sets, the classification information, and an explanation of the disorder. The diagnostic criteria set includes the symptoms that must be exhibited by the individual and the period of time that those symptoms must be an issue as well as the symptoms and disorders that must be ruled out prior to diagnosing a person with the disorder in question.The specifics of each mental health disorder will be defined by a range of symptoms at different severity levels impacted by the unique experience of the individual. Though everyone lives with a certain level of anxiety, depression, and other common mental health symptoms from time to time, experiencing symptoms that are severe enough to intrude on daily life and relationships for an ongoing period of time often indicates a mental health diagnosis.
- Prevalence of the disorder in the general population
- Details on how the disorder often develops and the course it generally takes
- Risk factors for the disorder as well as prognostic factors
- Measures for diagnosis
- Diagnostic features of the disorder
- Other features that are often an issue as well that also support a diagnosis of the disorder
- Diagnostic features of the disorder that are impacted by or related to cultural or gender issues
- How the disorder impacts the person’s ability to function
Why Is Underlying Mental Illness the Root Cause of Addiction?
In some cases, a mental health disorder predates the development of a drug or alcohol abuse disorder; in other cases, addiction becomes an issue first and mental health symptoms are not apparent until later — sometimes, they are triggered or worsened by drug use.
Everyone is different and there is no one cause of addiction, though living with a mental health disorder may increase the likelihood of developing an addiction disorder — and vice versa.
In most cases, a combination of issues may contribute to the development of addiction and/or mental health disorders, including:
- Biology:Some people are just wired so they are deeply attracted to the high created by drug and alcohol use. This may be due to prenatal development, early childhood exposures, accident, injury, or any number of possible things that could change the chemical makeup and function of the brain even slightly.
- Genetics:Having a close relative who struggles with drug or alcohol addiction may increase the likelihood of developing a substance abuse problem. Similarly, having a close relative with a mental health disorder may mean an increased chance of developing the same, or a similar, mental health issue.
- Trauma:Sexual abuse, physical abuse, natural disaster, and wartime experiences — exposure to trauma and near-death experiences can contribute to the urge to use drugs and alcohol as a coping mechanism as well as the experience of significant mental health issues, such as depression, post-traumatic stress disorder, anxiety, and more.
- Environment:Growing up or living in a home or other environment that is permissive of heavy drug use may contribute to the development of a substance abuse disorder
- Life Experience:Use of certain drugs and alcohol in high amounts as well as other significant life experiences, like developing a chronic illness, may contribute to the development of mental health symptoms.
Integrated treatment is a comprehensive rehabilitation program that offers all the medical, therapeutic, and holistic resources necessary to help clients heal physically, mentally, emotionally, and spiritually. No matter what the mental health diagnosis, but especially if co-occurring disorders are the issue, integrated care is recommended.
Why Integrated Treatment Is Recommended
Living with both a mental health disorder and substance abuse or addiction is a deadly combination. The poor lifestyle choices associated with these two disorders often translate into early and/or sudden death for the individual if no treatment is received.
Some common life-threatening issues that co-occur with a mental health disorder include:
- Heart disease
Recommended lifestyle changes that promote health and wellness at an integrated treatment program may include:
- Improving sleep habits
- Addressing any chronic medical conditions
- Improving communication skills
- Improving nutritional and eating behaviors
- Working on family relationships
- Addressing job skills and work-related issues
- Managing legal issues
What Does an Integrated Treatment Program Look Like?
Each client should have a unique treatment plan, but for those who are living with both a substance abuse or addiction disorder and a mental health disorder, an integrated treatment plan may typically include the option of:
- Medical detox: For many who struggle with addiction to drugs or alcohol, the detox period, or first days and weeks after the cessation of substance use, can be defined by physical and mental withdrawal symptoms. Detox services provide clients with medical support and monitoring if needed to help them stabilize in treatment.
- Evaluation: To ensure that all current mental health symptoms are accurately diagnosed, an evaluation is the next step in integrated treatment. Additionally, all other issues that may be an obstacle in the client’s path to recovery are identified.
- Diagnosis: Based upon the evaluation results and the reported experience of the client, diagnoses are made to help the client better understand and frame past experiences and plan for the future.
- Treatment plan: A unique treatment plan is created for each client that integrates a range of therapeutic and medical interventions with the goal of empowering the client to heal from addiction, learn how to manage mental health symptoms, and address any personal issues that may be problematic.
- Personal therapy: One-on-one therapy is the foundation of recovery, providing the client with a safe and confidential forum to discuss past experience, current issues, changes that occur in therapy, and goals for the future. As treatment goals are reached based on the initial treatment plan, the client can work together with the therapist to create new therapy goals and adjust the treatment plan accordingly.
- Group therapy: There are different types of groups that may be a part of an integrated treatment program: 12-Step groups, groups that focus on a specific aspect of addiction, a support group for people who share the same mental health issues, groups that help participants deal with a commonly shared life issue (e.g., parenting, legal problems, job seeking, etc.).
- Family therapy: Working together with loved ones to rebuild relationships damaged during active addiction and untreated mental health symptoms can play a significant role in recovery, especially if the client will be returning home to live with family members after treatment. Empowering family members to connect with treatment that will allow them to heal in their own ways while also working to help all members to learn positive communication skills.
- Aftercare plan: Before leaving treatment, clients are encouraged to work with a therapist to create a unique aftercare plan. Much like the treatment plan, this should include a unique combination of treatment services that will serve the treatment goals and needs of the client on an outpatient basis during and after the transition into independent living in recovery.
- Aftercare services & support: Clients who seek integrated treatment for co-occurring disorders are encouraged to create an integrated aftercare plan that incorporates services that address treatment needs on an ongoing basis. Continued mental health care is recommended as is support building in recovery from addiction and personal therapy as well as whatever holistic and alternative therapies were working for the client during treatment.
What Types of Mental Illnesses Can Be Treated at an Integrated Treatment Center?
There is no mental health disorder that cannot be effectively impacted by integrated treatment. According to
Medline Plus, some of the mental illnesses that will benefit from comprehensive medical and therapeutic care include:
- Bipolar Disorder
- Anxiety Disorders
- Obsessive-Compulsive Disorder
- Post-Traumatic Stress Disorder
- Personality Disorders
- Attention Deficit Hyperactivity Disorder
- Eating Disorders
Statistics, Facts, and Data
An estimated 17.3 million Americans over the age of 12 reported living with an alcohol use disorder in 2013, and about 6.9 million Americans in the same age group reported past year abuse of illicit drugs and/or addiction in a SAMHSA survey.According to the National Association for Alcoholism and Drug Abuse Counselors, women are at a higher risk for developing a dual disorder.1 Results from the 20018 National Survey on Drug Use and Health show that approximately 4.3 million women (about 3% of all women in the United States) have both a substance use disorder and a serious mental illness.2
It is not uncommon for a person to be diagnosed with co-occurring disorders. Those who present with symptoms of a substance abuse or addiction disorder are about twice as likely to also experience symptoms of a mental health disorder as compared to those who do not struggle with drug and alcohol use. By the same token, those who enter treatment for mental health symptoms that indicate a mental health disorder are likewise twice as likely to also be living with a substance abuse disorder.
SAMHSA says that an estimated 8.9 million Americans are living with co-occurring disorders. However, they also report that fewer than 7.5 percent of these people enroll in a comprehensive treatment program that can effectively address those disorders each year.
The most common causes of disability in the US are mental health disorders. This classification of disorder bears the largest disease burden of any disease or disorder. The National Institute of Mental Illness (NAMI) estimates that about one in 17 Americans or over 13 million people in the US are living with a serious mental illness or mental health disorder in any year.
An estimated 9.6 million Americans over age 18 were believed to be living with a serious mental illness (SMI) in 2012 — or about 4.1 percent of all adults in the US. In addition, it is estimated that about 20 percent of American kids under the age of 18 either had at one time or currently have a debilitating mental health problem.
The World Health Organization (WHO) reports that in the US and Canada, it is believed that about 25 percent of all years of life lost to premature death are caused by disability. Part of this number may be attributed to the high rates of suicide connected to mental health symptoms and disorders; about 30,000 Americans commit suicide every year, making the act the 11 th leading cause of death in the US.
Anxiety disorders are some of the most commonly diagnosed types of mental health disorders in the United States. More than 18 percent of Americans over the age of 18 struggle with anxiety, and about 23 percent of these people are diagnosed with a severe case. Incidentally, women are about 60 percent more likely to struggle with an anxiety disorder than men.
Major depressive disorder, dysthymic disorder, and bipolar disorder are among the disorders classified as mood disorders. These disorders are diagnosed among an estimated 9.5 percent of American adults over the age of 18, and about 45 percent of these clients have cases that are severe. Again, women are about 50 percent more likely to be diagnosed with mild, moderate, or severe depression, bipolar disorder, and other mood disorders than men. An estimated 14 percent of children between ages 13 and 18 are diagnosed with a mood disorder, with almost 5 percent classified as a severe case.
Antisocial personality disorder, borderline personality disorder, narcissistic personality disorder, and avoidant personality disorder — these are just a few of the many personality disorders that are diagnosed in more than 9 percent of the US population. Though these disorders are characterized by perspectives and behaviors that make it difficult for the person suffering to function effectively with others, it is estimated that only 39 percent of people living with a personality disorder get treatment.
Some of the most deadly mental health disorders are eating disorders (e.g., anorexia, binge eating disorder, and bulimia) because malnutrition and organ failure are common results of caloric and nutritional deprivation. Though it is often believed that teen and adult women are the only people living with eating disorders, an estimated 2.7 percent of children in the US are living with an eating disorder, and an estimated 10-15 percent of people living with anorexia and/ or bulimia are men.
Though it is believed to be an illness that only impacts children, attention deficit hyperactivity disorder (ADHD) is diagnosed among more than 4 percent of American adults and about 41 percent of these cases are classified as severe. Also, 9 percent of children between 13 and 18 are living with ADHD.
An estimated 1 of every 68 children is born with a disorder on the autism spectrum (ASD). Autism is a disorder that can have a wide range of impacts on social, cognitive, and behavioral function through adulthood, and it occurs five times more frequently among males as compared to females.
Frequently Asked Questions
- Feelings of joylessness, hopelessness, and sadness
- Feelings of guilt, low self-esteem, or worthlessness
- Low energy levels
- Disrupted sleep patterns
- Disrupted eating patterns
- Suicidal thoughts or behaviors
Depression symptoms may be triggered by acute events (e.g., job loss or threat of job loss, end of a relationship, death of a loved one, etc.) and may be normal, but if symptoms persist for more than six months, treatment is recommended. Treatment may include medications like tricyclic antidepressants (e.g., Prozac, Zoloft) and cognitive and/or behavioral therapies. Holistic treatments that lower stress levels and increase an overall sense of positive wellbeing are recommended.
- Jumping from one extreme emotion and personality phase to the next (e.g., excitable, chatty, and busy to morose, hostile, and lethargic)
- Mood phases that may last from a few days to a few weeks or even a few months
- Extreme disruption to sleeping and eating patterns depending upon the mood cycle
- Erratic behavior that makes working well with others or having functional relationships at home difficult to manage
It is often difficult to diagnose bipolar disorder, especially among those people who experience long mood cycles because the disorder can at first appear to be major depressive disorder or an issue related to substance abuse if that is part of the problem. Once diagnosed, clients will usually be treated with medications that may include antipsychotic medications, mood stabilizers, and/or antidepressants. Cognitive Behavioral Therapy, holistic therapies, family therapy, and alternative therapies may be an effective part of an integrated treatment program for bipolar disorder, especially when co-occurring disorders are in evidence.
- Flashbacks of trauma or abuse
- Rapid breathing
- Rapid heart rate
- Fear or avoidance of certain situations
- Overwhelming feelings of panic
- Obsessive thoughts or repetitive behaviors
- Irrational fears
Treatment for anxiety disorders will vary depending upon the triggering issues and the specifics symptoms that manifest and are intrusive in the person’s life. Exposure therapy is a form of Cognitive Behavioral Therapy that is very often successful in the treatment of certain anxiety disorders. Other therapy options may increase the client’s ability to manage symptoms or stop them before they start.
Medications may be helpful in this process as well. Benzodiazepines (e.g., Klonopin, Ativan), antidepressants (e.g., Zoloft, Lexapro, Celexa), and beta-blockers (e.g., Inderol) may be prescribed depending upon the situation.
- Natural disaster
- Terrorist attack
- Warzone experience
- Physical or sexual assault
- Witnessing the assault or death of another person
Other people living with PTSD may exhibit avoidant behaviors, making choices that allow them to avoid people, places, or situations that trigger memories of the traumatic event. They may also have memory loss or blackout spots in their memory that disallow them to remember specific details leading up to, during, or after the trauma.
Additionally, people living with PTSD may feel numb and unable to connect with others and/or feel extremely agitated and unable to sleep or relax for fear of what may happen. Many have problems with friends or family, have a hard time holding it together every day at work, and may no longer have any interest in things that once were a source of relaxation or amusement.PTSD treatment may include medication to help manage symptoms of anxiety, insomnia, depression, and/or panic as well as therapy to help process the experience of the trauma and learn how to manage and mitigate symptoms.
About 2.2 million Americans are believed to be living with OCD. Because a range of symptoms may play a role in the compulsive behaviors and emotions associated with the disorder, treatment often includes the use of antidepressant medications and/or anti-anxiety medications as well as Cognitive Behavioral Therapy.
- Stimulant medications: Some prescription stimulant drugs (e.g., Adderall, Vyvanse) are used to treat attention deficit and hyperactivity disorder in adults and children. They can assist in helping clients to manage compulsive behaviors and focus. Additionally, Vyvanse was recently approved to treat people struggling with severe binge eating disorder.
- Opiate medications: In some cases, for the treatment of heroin addiction, it may be appropriate to use the prescription painkiller methadone in a formulation designed specifically to meet the needs of clients in opiate detox under tight supervision of substance abuse treatment professionals.
- Sedative medications: Benzodiazepines (e.g., Xanax, Klonopin, Ativan) are often prescribed for the treatment of anxiety disorders and panic. They work relatively quickly and can help to quell acute symptoms affecting the central nervous system. For clients living with co-occurring disorders, their prescription may be connected to the substance abuse and addiction issue as they are an addictive and controlled substance.
- Antidepressant medications: Antidepressant medications (e.g., Zoloft, Lexapro, Prozac, Celexa) may be useful in the treatment of major depressive disorder as well as any other disorder, including substance abuse and addiction, bipolar disorder, anxiety disorders and more, that causes moderate to severe symptoms of depression that do not go away on their own.
- Antipsychotic medications: Atypical (e.g., Haldol, Thorazine) and typical (e.g., Risperdal, Seroquel) antipsychotic medications may be useful in the treatment of people who are living with bipolar disorder, schizophrenia, and other mental health disorders that cause symptoms like aural or visual hallucinations, breaks with reality, and other symptoms of psychosis. Recently, the FDA approved Vraylar, a once-daily atypical antipsychotic medication for the treatment of schizophrenia and bipolar disorder.
- Mood stabilizers: People who are diagnosed with bipolar disorder, borderline personality disorder, and other mental health disorders may benefit from mood stabilizers (e.g., Depakote) that aid in the balancing of erratic mood swings.
- Beta-blockers: People who experience panic attacks as a part of their mental health disorder may benefit from the use of beta-blockers (e.g., Inderol) to help manage the physical symptoms.
- A change in medication to a non-addictive choice
- Stopping use of the medication completely
- Therapy that addresses the urge to use medications compulsively
- Support groups that encourage alternative treatment options for the underlying disorder as well as relapse prevention
- Cognitive therapies and behavioral therapies: Therapies that focus on the perspectives upon which the client bases ultimately self-harming decisions and the assumptions that drive those perspectives are often healing for people in recovery from mental health and substance abuse disorders. Similarly, addressing the behaviors that may be automatic for clients but not ultimately serving their abilities to remain sober or manage mental health issues can help them to make shifts and changes that will improve their quality of life and their ability to better manage their mental health disorder, and also avoid relapse.
- Dialectical Behavior Therapy (DBT): A form of Cognitive Behavioral Therapy, DBT is designed to help patients who may experience suicidal thoughts and tendencies through learning how to accept the reality of what is, via mindfulness training rather than judging their experiences — or themselves — as good or bad.
- Interpersonal therapy: The improvement of the ability to communicate with others can not only serve to limit the misunderstandings that may be the source of difficulty but also improve the ability of the client to get needs met healthfully. This skill can improve individuals’ abilities to lower stress and thus increase their ability to manage intrusive mental health symptoms and avoid relapse.
- Family therapy: Couples counseling, parenting counseling, and other family therapies focus on primary relationships in the client’s life and empower loved ones to be of the most benefit during the recovery process.