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Dual Diagnosis
Signs | Symptoms | Treatments
“Dual diagnosis” refers to someone who has both a substance use disorder (alcohol or drug-related) and a mental health disorder at the same time. For instance, an individual with alcohol use disorder and major depressive disorder at the same time has a dual diagnosis. Having a dual diagnosis may also be referred to as having “co-occurring disorders,” or “comorbid disorders.” It is common for people with a substance use disorder to also have a co-occurring mental disorder, and vice versa. Having a dual diagnosis can make diagnosis and treatment more difficult. Many symptoms of substance use disorders and mental disorders overlap, and one disorder can worsen the symptoms of the other. Additionally, both disorders must be effectively treated, otherwise one’s recovery may be jeopardized.
What is a Dual Diagnosis/Co-Occurring Disorder?
Common Mental Health Disorders and Addiction
Substance use disorders can co-occur with any type of mental health disorder. Research indicates that mental disorders typically onset before substance use disorders do. Common mental health disorders that co-occur with substance use disorders are listed and described below:
“Dual diagnosis” refers to someone who has both a substance use disorder (alcohol or drug-related) and a mental health disorder at the same time. For instance, an individual with alcohol use disorder and major depressive disorder at the same time has a dual diagnosis. Having a dual diagnosis may also be referred to as having “co-occurring disorders,” or “comorbid disorders.” It is common for people with a substance use disorder to also have a co-occurring mental disorder, and vice versa. Having a dual diagnosis can make diagnosis and treatment more difficult. Many symptoms of substance use disorders and mental disorders overlap, and one disorder can worsen the symptoms of the other. Additionally, both disorders must be effectively treated, otherwise one’s recovery may be jeopardized.
Attention-Deficit/Hyperactivity Disorder (ADHD)
ADHD begins in childhood and can continue into adulthood. It is characterized by inattentiveness and/or hyperactivity and impulsivity. Symptoms of inattention include difficulty with paying attention and staying focused, making careless mistakes, difficulty with following instructions or finishing work, being easily distracted, and often losing items or forgetting to do things. Symptoms of hyperactivity and impulsivity include difficulty sitting still and staying seated, difficulty engaging in activities quietly, acting as if “driven by a motor,” talking excessively, blurting out answers, and interrupting others. An individual with ADHD may have predominantly inattentive symptoms, predominantly hyperactive/impulsive symptoms, or a combination of both. People with ADHD typically also experience irritability, mood swings, and a low frustration tolerance. According to the National Comorbidity Survey Replication, 15.2% of people with ADHD also met criteria for a substance use disorder. 3
Antisocial Personality Disorder
People with antisocial personality disorder have a behavioral pattern of disregarding and violating the rights of other people. They exploit, manipulate, and deceive others, without any remorse. Additionally, they often break the law, lack empathy, and behave violently, impulsively, and irresponsibly. They lack regard for the safety of themselves and of others. In order to be diagnosed with antisocial personality disorder, the individual must have shown a similar behavioral pattern of violating major norms, rules, or the rights of others before the age of 15. Antisocial personality disorder is most prevalent among males with substance use disorders and males who are in prisons.
Bipolar Disorder
Bipolar disorder is characterized by experiencing extremely high and low moods. More specifically, people with bipolar disorder experience episodes of mania and depression. Manic episodes consist of an extreme elevation in one’s mood, energy, and activity levels. During a manic episode, people typically experience feelings of euphoria, an inflated self-esteem, are extremely talkative, have a flight of ideas, and have a decreased need for sleep. They often feel restless and excessively driven to engage in multiple projects or activities, including ones that can lead to harmful consequences, such as spending sprees or sexual promiscuity. During depressive episodes, people typically feel intense sadness, lack of interest in previously enjoyed activities, loss of energy, feelings of hopelessness or worthlessness, and thoughts of death. People with bipolar disorder are about seven times as likely as others to have a co-occurring substance use disorder. In terms of lifetime prevalence, about 56% of people with bipolar disorder have a co-occurring substance use disorder. 4
Borderline Personality Disorder
People with borderline personality disorder demonstrate a pattern of unstable relationships, sudden mood swings, and issues with self-image. They also have intense fear of abandonment, which leads them to have extreme difficulties with being alone. In their interpersonal relationships, they may alternate between idealizing others and then suddenly devaluing them. Additionally, they often experience rapid and extreme changes in their mood, and have difficulty controlling their anger. Moreover, as their sense of self is unstable, they may rapidly and repeatedly change their self-image, goals, opinions, wants, and needs. People with borderline personality disorder typically engage in impulsive behaviors that lead to self-destructive consequences. For instance, they may abuse substances, drive recklessly, or have unsafe sex. They may also engage in self-mutilation or suicidal behavior. About 50% of people with borderline personality disorder have a co-occurring substance use disorder, which is most commonly alcohol use disorder.5
Eating Disorders
About 50% of people with eating disorders also abuse alcohol or drugs 6 . Two types of eating disorders that are commonly associated with substance use disorders are anorexia nervosa and bulimia nervosa. People with anorexia nervosa have an unrealistic body image and an intense fear of gaining weight. They severely restrict their food intake, despite being significantly underweight. People with bulimia nervosa engage in periods of binge eating, in which they consume excessively large amounts of food and feel like they have a loss of control once they start eating. In order to prevent weight gain, they engage in inappropriate purging behaviors, such as vomiting, fasting, misusing laxatives, or exercising excessively. In both anorexia nervosa and bulimia nervosa, people may abuse substances, such as stimulants, as a way to suppress their appetite. However, overall, research suggests that there is a stronger connection between bulimia nervosa (rather than anorexia nervosa) and drug and alcohol abuse.
Generalized Anxiety Disorder
People with generalized anxiety disorder (GAD) experience persistent, excessive anxiety and constantly worry about numerous different things. Their constant worrying and nervousness interferes with their daily functioning and their ability to concentrate and relax. GAD is highly linked to co-occurring substance use disorders. It is likely that individuals with GAD self-medicate with substances to relieve anxiety symptoms. One study found that in comparison to individuals with GAD alone, those with GAD and a co-occurring substance use disorder are more likely to be male and have a family history of substance use disorders.7
Major Depressive Disorder
Major depressive disorder is characterized by persistent feelings of sadness and lack of interest or pleasure in things that were once enjoyed. People with major depressive disorder may also have decreased energy, difficulty concentrating or making decisions, feelings of worthlessness or hopelessness, and suicidal ideation. Moreover, they may experience changes in their appetite (either increased or decreased) and in their sleep (insomnia or oversleeping). People with major depressive disorder are about two times as likely as others to have a co-occurring substance use disorder. In terms of lifetime prevalence, about 16.5% of people with major depressive disorder also have co-occurring alcohol use disorder, and about 18% have a co-occurring drug use disorder.8
Obsessive-Compulsive Disorder (OCD)
People with obsessive-compulsive disorder (OCD) experience recurring unwanted, distressing thoughts (obsessions) and perform repetitive mental acts or behaviors (compulsions) in response to them. Common obsessions include germs or contamination and taboo or aggressive thoughts. Common compulsions include excessive washing, checking, or counting. OCD is time-consuming and causes significant psychological distress and impairment in one’s functioning. About 38.6% of people with OCD also have a co-occurring substance use disorder.9
Panic Disorder
Panic disorder is a type of anxiety disorder in which individuals experience repeated, unexpected panic attacks, without any apparent cause. Panic attacks are sudden surges of extreme fear, accompanied by physical symptoms of anxiety, such as pounding heart, trembling, shortness of breath, chest pain, sweating, dizziness, and choking sensations. People with panic disorder constantly worry about having more panic attacks, which can severely impair their functioning and quality of life. Panic disorder is highly associated with co-occurring substance use disorders, particularly with alcohol use disorder.10 It is possible that people with panic disorder may abuse alcohol in attempt to decrease panic attack symptoms.
Posttraumatic Stress Disorder (PTSD)
Posttraumatic stress disorder (PTSD) can develop after someone is exposed to a traumatic event. People with PTSD continuously re-experience the traumatic event, such as through bad dreams or flashbacks, and they avoid anything that reminds them of the traumatic event. Additionally, they experience negative changes in their thinking and mood that are related to the traumatic event. Moreover, they become easily aroused and reactive, wherein they may be excessively irritable, hypervigilant, startled easily, and have problems sleeping. Research has consistently demonstrated that PTSD and substance use disorders frequently co-occur. One study found that 34.4% of people with PTSD had a co-occurring substance use disorder, which was most commonly alcohol use disorder.11
Schizophrenia
Schizophrenia is a serious mental disorder that causes difficulties in perceiving reality accurately, thinking and speaking, and interacting with others. People with schizophrenia experience hallucinations (perceiving something that is not there) and/or delusions (false beliefs). Additionally, they may experience disorganized thinking and speech and exhibit abnormal behavior. They may also have negative symptoms, which include flat affect, social withdrawal, inability to feel pleasure, and lack of interest and motivation. In terms of lifetime prevalence, it is estimated that about 47 to 59 percent of people with schizophrenia have a co-occurring substance use disorder.12
Why do Substance Use Disorders and Mental Disorders Occur Together?
In individuals with a dual diagnosis, it is difficult to determine whether the substance use disorder or mental illness developed first. It is possible that an individual with a mental illness may self-medicate with substances to alleviate his or her symptoms, which could lead to the development of a substance use disorder. It is also possible that abusing substances may lead one to develop a mental disorder, such as by changing brain structure and function. Additionally, abusing substances may also exacerbate symptoms of a preexisting mental disorder. However, even if a substance use disorder or mental disorder developed first, one does not necessarily cause the other. While it remains unclear why so many people have a dual diagnosis, there are various shared risk factors for mental disorders and substance use disorders, including:
Genetic vulnerability
Environmental factors and influences
Interactions between genetic vulnerability and environmental factors
Brain regions, including circuits that mediate reward, emotions, impulse control, and decision making
Brain chemistry, including neurotransmitter systems
Stress
Trauma
Adverse childhood experiences
Warning Signs and Symptoms of a Dual Diagnosis
It can be difficult to identify when someone has a dual diagnosis, especially since the symptoms can vary greatly depending on the substance use disorder and the mental disorder an individual has. For instance, a person with alcohol use disorder and depression can have very different symptoms than a person with stimulant use disorder and anxiety. However, some common symptoms of a dual diagnosis may include:
Extreme changes in mood or sudden mood swings
Withdrawal from family, friends, and social activities
Concentration problems
Difficulty controlling emotions
Problems with employment or keeping a job
Issues with maintaining relationships
Decreased work or school performance
Financial problems
Legal problems
Treatment for Dual Diagnosis
Having a dual diagnosis complicates treatment and increases the risk for relapse. Additionally, patients with a dual diagnosis are more likely to be noncompliant with treatment or drop out of treatment early. Furthermore, patients who have a substance use disorder and a mental disorder at the same time experience more severe and persistent symptoms than patients who only have one disorder. If a patient receives treatment for only one disorder while the other is left untreated, it could severely negatively affect his or her treatment progress. Therefore, effective treatment for dual diagnosis involves simultaneously treating both the substance use disorder and the mental disorder. This is referred to as integrated treatment, in which multiple interventions are used in order to comprehensively treat both co-occurring disorders in the patient. Integrated treatment may involve combining psychotherapy, medication, education, and other behavioral treatments. Integrated treatment also often involves interdisciplinary teams, wherein multiple clinical providers from different fields collaborate together to best serve each patient. Research has continuously found that using an integrated treatment approach for dual diagnosis patients is more effective than using a single focused treatment approach. Additional treatments for dual diagnosis patients are described below. Each treatment option may be utilized alone, or in combination with others as a part of an integrated treatment plan.
Detoxification
Detoxification, or detox, is often the first step of substance abuse treatment. It involves safely eliminating the drug or alcohol from a patient’s body. Health professionals support patients and help them manage the physical and psychological withdrawal symptoms that are experienced from prolonged substance abuse. In medical detox, medications are prescribed to help ease withdrawal symptoms. Detox programs are offered in either inpatient or outpatient settings, although inpatient detox is most effective since patients can be monitored 24 hours a day. It is recommended that upon completing detox, patients continue to remain in treatment, such as in inpatient or outpatient treatment centers. A study from John Hopkins found that patients completing detox treatment alone have high relapse rates, between 65 to 80 percent. However, patients continuing to receive treatment after completing detox were up to 10 times more likely to stay sober.
Medication
In addition to being used during detoxification to ease withdrawal symptoms, medications may also be used to treat symptoms of mental disorders in dual diagnosis patients. There are several different types of medications for various mental disorders. The medication(s) prescribed to dual diagnosis patients will vary based on each patient’s mental health symptoms. Common types of medications for treating mental disorders in dual diagnosis patients include:
Mood stabilizers
Sedatives/Hypnotics
Beta blockers
Antidepressants
Antipsychotics
Individual Psychotherapy
One-on-one psychotherapy is a vital aspect of treatment for dual diagnosis patients. Behavioral therapies are commonly used to treat these patients. Cognitive behavioral therapy (CBT) in particular is a highly effective type of behavioral therapy for treating substance use disorders and various mental disorders. CBT helps patients understand the relationship between their thoughts, feelings, and behaviors. Additionally, it helps patients identify their negative thinking patterns, emotions, and other triggers that lead to maladaptive behaviors, such as substance abuse and self-medicating. Patients receiving CBT will learn adaptive ways to cope with their negative thoughts, feelings, and mental health symptoms that lead to substance abuse and other undesirable behaviors. Other therapeutic techniques that are used by therapists to effectively treat dual diagnosis patients include:
Mindfulness-based interventions
Guided imagery
Breathing exercises
Progressive muscle relaxation
Relaxation techniques
Group Therapy
Like individual therapy, group therapy is often another major component of treatment for dual diagnosis patients. There are several advantages of group therapy, including:
Allowing patients to feel encouraged and supported by others who have experienced similar difficulties to them
Allowing patients to witness others’ recovery, which can motivate and inspire them in their own recovery
Allowing patients to receive helpful feedback from other group members, especially about distorted beliefs they may have
Helping patients who are new to recovery learn valuable information and gain new insights
Helping patients learn new ways to cope with their difficulties by hearing how others have done so
Giving patients the opportunity to learn and improve social skills and how to effectively interact with others, in a supportive environment
Inpatient Rehab
Inpatient rehabs are residential treatment programs. This means that patients will stay at the treatment center for the duration of treatment, which will typically be from 30-90 days. Here, they will receive ongoing medical and emotional support from a team of professionals, including psychiatrists, therapists, and counselors, 24 hours a day. Inpatient programs are more intensive than outpatient programs. They also provide a controlled and structured environment for patients to recover in, away from outside distractions. Thus, they are ideal for dual diagnosis patients experiencing more severe addictions and mental health symptoms. In inpatient dual diagnosis programs, patients will typically receive daily therapy, attend groups daily, and regularly receive education about both substance use disorders and mental health issues.
Outpatient Rehab
Outpatient rehabs are less intensive and offer more flexibility than inpatient programs. In outpatient rehab programs, patients live at home and come to a treatment center for a certain amount of hours each week. Outpatient programs vary in intensity, but typically 6 to 30 hours of treatment is provided to patients each week. Thus, outpatient programs are ideal for patients who want to continue living with their families and going to work or school while receiving treatment. Many patients finishing treatment at inpatient rehabs choose to continue their recovery at outpatient rehabs. In outpatient dual diagnosis treatment programs, patients will receive individual therapy and attend multiple groups each week. Patients can also meet with psychiatrists for medication, if necessary. Outpatient rehab programs typically last three months to a year, or even longer.
Self-Help Groups
In self-help groups, people who share a common problem come together and provide mutual support to one another. Social support has been shown to enhance mental health and quality of life, including in individuals with substance use disorders and mental disorders. Additionally, it has been found that people participating in dual diagnosis self-help groups reported decreased mental health distress and substance use. Therefore, attending self-help groups can be extremely beneficial for people with a dual diagnosis. Alcoholics Anonymous and Narcotics Anonymous are popular self-help groups for people with substance use disorders.
Some common self-help groups specifically for people with a dual diagnosis are:
Double Trouble in Recovery
Double Trudgers
Dual Recovery Anonymous
Resources
- https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.pdf
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3327759/
- https://www.researchgate.net/publication/7195472_The_Prevalence_and_Correlates_of_Adult_ADHD
_in_the_United_States_Results_From_the_National_Comorbidity_Survey_Replication - https://www.ncbi.nlm.nih.gov/pubmed/11448377
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145127/
- https://www.centeronaddiction.org/addiction-research/reports/food-thought-substance-abuse-and-eating-disorders
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951633/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860396/
- https://ajp.psychiatryonline.org/doi/full/10.1176/ajp.2006.163.4.652
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851027/
- https://cpb-us-w2.wpmucdn.com/web.sas.upenn.edu/dist/3/176/files/2016/07/2010_-_ruscio_et_al.-1qpwqcv.pdf
- https://www.uptodate.com/contents/co-occurring-schizophrenia-and-substance-use-disorder-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis
- https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/why-there-comorbidity-between-substance-use-disorders-mental-illnesses
- https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/what-are-treatments-comorbid-substance-use-disorder-mental-health-conditions
- https://www.hopkinsmedicine.org/news/media/releases/drug_free_housing_for_substance_
abusers_leaving_detox_linked_to_fewer_relapses - https://www.ncbi.nlm.nih.gov/books/NBK64223/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1868661/
