Individuals turn to the misuse and abuse of drugs and alcohol for a number of different reasons. Often, some of the core feelings that drive and maintain substance use disorder are related to what psychologists label as negative affect or negative affectivity.
Everyone experiences temporary feelings of sadness, disappointment, and inadequacy. Feeling sad or down is associated with experiencing a number of events that occur as a result of living in the world, and these feelings are normal parts of the ups and downs of human existence. Simply experiencing normal shifts in mood is not associated with the development of a significant substance use disorder. However, individuals who experience extreme feelings of sadness, ineptitude, skepticism about the future, and other related emotions that occur for a significant length of time and lead to a significant decline in their ability to engage in the normal aspects of their lives may have a serious mental health disorder.Major depressive disorder is a clinical diagnosis that is given to individuals when their experience of being depressed results in a number of issues with functioning, overall outlook on life, and an inability to enjoy the positive aspects of life. These feelings and the effects associated with them are considered to be in excess of what would be considered “normal” and lead to significant dysfunction or distress in the person’s daily living.
There are no formal medical tests or laboratory tests that can interpret specific biological signs in individuals to determine if their emotional states have become pathological. For example, there are no neuroimaging tests, blood tests, x-rays, etc., that can be used to diagnose major depressive disorder in anyone. Instead, the diagnosis of major depressive disorder (as is the case with the majority of mental health disorders) can only be made by a licensed professional mental health clinician, such as a psychiatrist, psychologist, social worker, etc. The diagnosis is made based on a number of behavioral signs and symptoms that are observed during a formal assessment of the person’s behavior and functioning. These signs and symptoms must occur for a minimum of two weeks and cannot be better explained by other factors, such as another mental health disorder, some physical problem or medical disorder, or as a direct result of using some drug.
The American Psychiatric Association (APA) lists a number of potential diagnostic criteria for major depressive disorder. The person must meet a minimum of five of the criteria over the same two-week period in order for the individual to receive a formal diagnosis. While the diagnostic criteria will not be formally listed here, they consist of symptoms like the following:
- Sadness for most of the day nearly every day
- Feelings of guilt or worthlessness for most of the day almost every day
- Marked loss of interests or difficulty experiencing pleasure nearly every day
- Weight loss
- Weight gain
- Inability to sleep
- Increase in sleep
- Loss of energy
- Irritability or restlessness
- Decrease in appetite
- Increase in appetite
- Slowing Motor Skills
- Cognitive signs that include significant difficulties with attention, decision-making, and memory
- Recurrent thoughts about death or self-harm
APA has also recognized a number of specific presentations of people diagnosed with depression that are not typical, and these are also listed in the formal diagnostic scheme. For example, most people with clinical depression experience an inability to sleep, weight loss, and a loss of appetite, but some individuals may actually experience the opposite symptoms, such as increased sleep, weight gain, and increased appetite.Major depressive disorder or clinical depression is one of the most debilitating yet most commonly diagnosed mental health disorders in the United States. In addition, individuals diagnosed with clinical depression are at a high risk to be diagnosed with other co-occurring disorders. As a general rule of thumb, it is accepted that at least one-third of individuals who have a major depressive disorder diagnosis will also have some form of substance use disorder. The most common substance use disorder associated with major depression is alcohol use disorder, but individuals may display the symptoms that meet the diagnostic criteria for any substance use disorder.
The reason that major depression and substance use disorders are interrelated is not as straightforward as most people believe. Many people believe in what is formally termed as the self-medication hypothesis where individuals who have psychological disorders or experience psychological distress use drugs and alcohol to medicate their symptoms. While this may explain some of these co-occurring issues some of the time, this explanation is not satisfactory in a good number of co-occurring diagnoses. It is far more likely that individuals who have any type of mental health disorder have a number of risk factors that make them more vulnerable for the development of other psychological disorders. These risk factors can include genetic factors, environmental factors, and interactions between the two. In other words, simply qualifying for diagnosis of one mental health disorder results in an increased probability that one will be diagnosed with another mental health disorder.
This also means that individuals who have these co-occurring conditions will experience exacerbations of both issues, as these conditions tend to “feed off” one another. An individual with a substance use disorder will consume more of their substance of abuse, and this will lead to a greater number of functional impairments, which can lead to greater issues with clinical depression, etc.
Someone with a major depressive disorder may become isolated, pessimistic, and self-destructive, and this can lead to increased substance abuse, which in turn will exacerbate the negative symptoms of clinical depression, etc.
It is long been known that when individuals are diagnosed with co-occurring disorders, it is not possible to focus on treating one disorder and hope that the other will resolve as a result of one disorder being treated. Instead, clinicians recognize that individuals need both disorders to be treated concurrently in order for them to be successful in recovery.
Like depression, everyone experiences some level of anger in life related to certain frustrating events that occur. Emotions like anger and sadness are not necessarily bad, as all emotions have functional attributes. When emotions become very extreme, rigid, endure for significant periods of time, and result in inappropriate expressions that lead to distress or dysfunction, the emotions themselves are considered to be part of the overall dysfunctional picture.
Extreme anger or difficulty with anger management represents another potential devastating aspect of negative affect that is important to consider in individuals who are in recovery for substance use disorders. Issues with anger have become more visible in a number of aspects of American society, including polarization over major political issues, issues surrounding terrorism, issues surrounding immigration, etc. On an individual level, anger management issues also lead to a number of negative outcomes, including frustration, resentfulness, regret, depression, feelings of decreased self-worth, or engaging in potentially self-destructive behaviors.
Psychologists studying emotions generally divide emotions into three components. The Everything Guide to the Human Brain lists these three components of emotions like anger as follows:
- The cognitive component includes what one thinks about their feelings (e.g., anger). This component consists of perceptions regarding what the person believes leads to anger, how they should act on their anger, what they believe reduces their anger, etc.
- The physical component of anger includes changes in the body, such as changes to heart rate, blood pressure, breathing rate, etc., associated with the emotion. Often, anger is linked to the fight-or-flight phenomenon in terms of the physical associations with anger; for anger, this would represent the fight aspect of this phenomenon.
- The behavioral component of anger includes everything the person actually does to express their anger.
The dysfunctional and pathological expression of anger is associated with a number of mental health disorders as well. When anger becomes very intense, rigid, and a major way to cope with issues in life, the perception and expression of anger can become dysfunctional. For example, oppositional defiant disorder in children and intermittent explosive disorder in adults represent two cases of intense, rigid, and inappropriate expressions of anger that are the major components of mental health disorders. Other disorders, such as certain types of personality disorders, are also associated with individuals who have very intense, rigid, and inappropriate expressions of anger. Individuals who have difficulty with anger management often have a number of other issues that can be very frustrating, such as making poor decisions, having relationship issues, having issues with work, or having issues with the legal system.A number of organizations, including APA and Alcoholics Anonymous, have recognized that issues with anger and the expression of anger or managing anger can lead to an exacerbation of substance abuse. The relationship between anger and substance abuse is most likely more complicated than generally envisioned.
The relationship between anger and substance abuse, like the relationship between substance abuse and depression, is most likely multidirectional, such that exacerbations of anger can result in potential substance abuse, and an individual abusing drugs or alcohol may have an exacerbation of negative affect (e.g., anger or frustration). Again, in many instances, this can result in spiraling effects that “feed off” one another and exacerbate both conditions. This situation requires that both conditions be treated simultaneously. Individuals who have anger management issues need professional intervention for these issues along with formal substance use disorder treatment in order for treatment to be successful in resolving either issue.
The use of integrated treatment approaches is suggested for individuals who have co-occurring disorders, such as depression and substance abuse or issues with anger management and substance abuse. Integrated treatment is delivered by a multidisciplinary team of physicians and therapists who work together to address the individual as an entire person. This holistic treatment approach is designed to follow an overall blueprint that is individualized to the specific needs of the person being treated.
The treatment team typically consists of physicians (psychiatrists and/or addiction medicine physicians and specialists who may be needed for specific medical conditions), mental health workers (e.g., psychologists, counselors, social workers, etc.), other therapists or specialists in specific areas that need to be addressed (e.g., speech therapists, occupational therapists, vocational rehabilitation therapists, etc.), and other professional individuals and even volunteers. The treatment approach would typically consist of the following components:
- A complete assessment of the individual’s physical, cognitive, and emotional functioning in order to identify both strengths and weaknesses and problems to be addressed
- Potential placement in medical detox for individuals who may have developed physical dependence on one or more substances
- Substance use disorder therapy, which is specialized and targeted at issues associated with substance use disorders: Most often, this is some form of Cognitive Behavioral Therapy (CBT) that includes a significant psychoeducational component. CBT will help the individual to understand the underlying reasons for substance abuse, identify their irrational beliefs, help the individual to change these irrational beliefs and resulting behaviors, etc.
- Therapy for depression and/or for anger management: The preferred approach for both of these issues is also CBT; however, the specific aspects of the therapy are tailored for either depression or anger management techniques. Therapy for depression consists of identifying irrational beliefs that lead to feelings of depression and associated behaviors, changing these beliefs, and helping the individual develop more functional approaches to life. Anger management techniques focus on the three aspects of anger – cognition, physical feelings, and behaviors – in an attempt to identify the irrational features of these and address them. While there is some overlap between substance use disorder therapy and specific therapy for depression or anger management, these issues can also be addressed separately. Depending on the therapists involved, the same therapist can address these issues, or different therapists may be involved in treating them.
- Medical management for depression, for any physical problems, and for issues related to the individual’s substance abuse
- Other interventions as needed in the specific case, such as tutoring, job training, speech therapy, etc.
- Social support participation, which can include family therapy, attendance at 12-Step meetings, volunteer work, etc.
- Continued long-term aftercare
The integrated treatment approach is typically designed to involve the individual in a long-term program of intervention and self-discovery. Individuals will often continue in some form of aftercare, such as social support group participation and periodically checking in with therapists and doctors, for years following the initial referral.
Co-Occurring Disorders Treatment Guide
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