Most of us know someone personally who struggles with a dual diagnosis, or the presence of a substance use disorder and coexisting mental health disorder. Many people rely on the numbing effects of a substance to help them manage a difficult mental health issue. Sadly, the end result is often two co-occurring disorders that only enhance the sense of despair and further complicate the treatment picture.
Battling a dual diagnosis is more challenging because of the complexity of each specific case, needing to factor in the various mental health conditions and substance use disorders that can co-occur. Another consideration affecting the treatment protocol is identifying which disorder emerged first, the mental health disorder or the substance use disorder. However, regardless of the order in which the disorders developed, for the best recovery outcome it is recommended that both co-occurring disorders be treated at the same time.
Many who live with co-occurring disorders suffer in silence, remaining under the radar and never seeking treatment for the condition. This can lead to social isolation, making it difficult for friends or coworkers to know what is going on. The symptoms of the two co-occurring disorders may go unnoticed if the individual is adept at concealing them, only increasing the potential health risks.
About Co-Occurring Disorders
More than 9 million Americans struggled with co-occurring disorders in 2018, according to the Substance Abuse and Mental Health Services Administration. Statistics indicate that roughly 50% of the 19.7 million adults with a substance use disorder also have a coexisting mental health condition. Rates of dual diagnosis are highest among adults ages 26-49.
Living with co-occurring disorders will have a negative impact on health, career, family, and interpersonal relationships. Each disorder increases the effects of the other, meaning that the usual symptoms of depression, for example, are exacerbated by the substance used for self-medicating. The fallout of the substance use disorder will likewise be exacerbated in response to the mental health disorder.
A dual diagnosis treatment program will provide targeted and integrated treatment protocols for both types of disorders. The clinical staff will include a physician, addiction recovery specialists and therapists, and a psychiatrist. These specialized programs are equipped to manage the more complex features of co-occurring disorders.
Signs of Co-Occurring Disorders
The diagnosis process for co-occurring disorders is complicated. Because each person’s particular combination of disorders, and the specific features attributed to each, is unique it requires a very thorough assessment at the outset. Someone with PTSD and co-occurring alcoholism will present with very different symptoms from someone struggling with an anxiety disorder and co-occurring Xanax dependency. However, there are certain signs and symptoms that are often present with co-occurring disorders, such as:
- Unpredictable mood swings
- Irritability or anger issues
- Inability to keep a job
- Inability to maintain healthy relationships
- Financial difficulties
- Impaired social functioning
- Emotional instability
- Ignoring obligations and responsibilities
- Withdrawing from friends and family
- Erratic or unpredictable behavior
- Legal problems
- Exhibits withdrawal symptoms when not using the substance
- Increasing consumption of alcohol or drugs
- Heightened suicide risk
When co-occurring disorders result in the loss of normal daily functioning, it is appropriate to seek out a treatment program that offers specialized dual diagnosis support.
Common Co-Occurring Disorders
When the mental health disorder is the first of the co-occurring disorders to develop, it is common for individuals to seek relief from the symptoms through the use of a substance. Some of the most common combinations of co-occurring disorders include:
Depression impacts 17.3 million American adults each year. Individuals who struggle with depression may lean on alcohol to help them numb the depression symptoms. The symptoms can be so difficult to bear that the soothing effects of alcohol provides some relief and a temporary escape from their present suffering. These include:
- Sadness, despair, hopelessness
- Change in appetite, weight loss or gain
- Loss of desire to participate in usual activities
- Sleep disturbances, insomnia or hypersomnia
- Slowed motor and cognitive functioning
- Irrational feelings of shame or guilt
- Trouble concentrating or making decisions
- Suicidal ideation
The consequences of this dual diagnosis can be significant. Struggling with both depression and alcohol dependency can result in increased impulsivity and risk-taking behaviors, increasing the risk for suicide.
Anxiety Disorder with Benzodiazepine Addiction.
Anxiety disorders affect over 40 million people each year. For many who suffer with an anxiety disorder, such as panic disorder or generalized anxiety disorder, relief is found through prescription sedatives (benzodiazepines), such as Xanax, Ativan, or Valium, which can help relieve some of the following symptoms:
- Racing heart
- Increase in blood pressure
- Shallow breathing
- Intense worry or feelings of dread and fear
When a benzodiazepine addiction develops as a response to the anxiety symptoms it is difficult to stop the medication because the withdrawal symptoms are very intense. No one should attempt to stop benzodiazepines cold turkey, as dangerous health risks can emerge. Instead, a doctor will arrange for a medically monitored detox involving incrementally reducing the dosing over a period of two weeks.
PTSD with Alcoholism, Opioid, or Heroin Addiction.
Individuals struggling with the effects of prolonged trauma may opt to use a substance as a means of numbing their emotions and trauma symptoms. Individuals with PTSD gravitate toward alcohol, prescription opioids, or heroin. Over time, however, as the PTSD symptoms continue to linger the drug or alcohol use can result in a substance use disorder.
- Flashbacks, nightmares, or trauma-related triggers that cause the individual to replay the traumatic event over and over again.
- Avoiding places, situations, or people that provoke disturbing memories of the event.
- Hyperarousal, feeling jittery, easily excitable or startled
- Emotional numbness, detachment
- Angry outbursts
Social Anxiety with Marijuana Misuse
Social anxiety can be debilitating, with symptoms so troubling that individuals may become isolated in their attempt to avoid experiencing the discomfort of the disorder. For some, the only way they can approach a social event or anxiety-provoking situation is by self-medicating with marijuana. The relaxing effects of cannabis helps them to be able to function in social situations. Unfortunately, marijuana misuse can lead to psychological addiction, meaning that the person feels that they can not possibly attend a social event without the drug.
Social anxiety symptoms:
- Intense fear of being judged or criticized by others
- Racing heartbeat
- Avoiding social settings
- Isolating behaviors
Bipolar Disorder with Alcohol Addiction
Bipolar disorder is a challenging mental health disorder which features intense mood swings between manic and depressive episodes. Bipolar disorder is extremely destabilizing and can lead to significant impairment. To help manage the effects of the mood swings the individual may self-medicate with alcohol, which can lead to a dual diagnosis.
Depressive episodes symptoms:
- Persistent sadness
- Intense fatigue
- Feelings of hopelessness and despair
- Sleep disturbances
- Loss of interest in life
- Chronic pain with no known medical cause
- Trouble concentrating
- Suicidal ideation
Manic episode symptoms:
- Racing thoughts
- Rapid speech
- Aggressive behavior
- Decreased sleep
- Impulsive behaviors
- Risky behaviors
- Psychosis, including paranoia, delusions, or hallucinations
A dual diagnosis can also occur in the reverse, with the substance use disorder as the root cause of a mental health condition. For example, depression can result due to the devastating consequences caused by alcoholism. Also, some illicit drugs, such as cocaine or methamphetamine, can lead to psychotic disorders.
Integrated Treatment for Co-Occurring Disorders
Treatment for co-occurring disorders integrates targeted psychiatric support within the addiction rehabilitation program. Abstinence in recovery will not be achieved unless the coexisting mental health issue is also addressed and treated. Dual diagnosis treatment is a complicated process, requiring specialized skills and expertise for a successful recovery outcome. This is because unpredictable psychological withdrawal symptoms could emerge, necessitating the need for a mental health professional to be available on site to assist in stabilizing the individual.
Treatment for Co-Occurring Disorders:
DETOX. Dual diagnosis treatment begins with the detox phase of recovery. Upon cessation of the substance of abuse, the individual will experience physical and mental withdrawal symptoms. During a medical detox, the individual will be provided with medical and psychological support until stabilized.
EVIDENCE-BASED PSYCHOTHERAPY. There are various types of psychotherapy available that provide a framework for making fundamental changes in thought patterns and behavioral responses. Together the therapist and client will determine recovery goals and benchmarks to be met while in treatment. Evidence-based therapies may include dialectical behavior therapy, cognitive behavioral therapy, prolonged exposure therapy, contingency management, and psychodynamic therapy.
GROUPS. Group therapy is an intrinsic component in dual diagnosis treatment. These gatherings promote peer support during rehabilitation, providing a safe space to share personal stories and discuss challenges in recovery. Family-focused therapy sessions and/or couples counseling help to rebuild damaged relationships and improve relationship skills.
MEDICATION. Psychotropic drugs that target the specific mental health disorder may be utilized in treatment and beyond rehab. These medications include antidepressants, benzodiazepines, antipsychotic medications, and mood stabilizers. For the substance use disorder, medication-assisted treatment (MAT) may be indicated. These drugs can help to sustain abstinence in early recovery by incrementally reducing the desire for the substance.
RECOVERY SUPPORT. Twelve-step programs, or alternatives like SMART Recovery, are often integrated into the rehabilitation program. These programs feature a distinct set of recovery steps or goals to achieve, as well as providing recovery meetings in the community.
ADJUNCTIVE THERAPIES AND RECREATION. Rounding out the dual diagnosis program are assorted activities that can further enhance the therapeutic effects of treatment. These might include yoga, mindfulness meditation, art therapy, massage, equine therapy, golf, tennis, hiking, and a gym.
While co-occurring disorders pose a more challenging diagnostic and treatment protocol, within a dual diagnosis treatment setting the individual will be guided toward successfully achieving their recovery goals.
If you or someone you know experiences mental health issues, it is important to seek help from a qualified professional. Our Resource Specialist can help you find expert mental health resources to recover in your community. Contact us now for more information on this free service to our users.
About the Author
Patty Bell is the Relations Manager and Interventionist of Capo By the Sea, a luxury addiction and dual diagnosis treatment program located in South Orange County, California. Patty’s passion to share her own positive experience with others, while being a living example of the freedom found in recovery, is what motivates her to guide clients toward their own stable, long-term recovery.
The opinions and views expressed in this guest blog do not necessarily reflect those of www.rtor.org or its sponsor, Laurel House, Inc. The author and www.rtor.org have no affiliations with any products or services mentioned in this article or linked to herein.
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