When someone has a dual diagnosis, both disorders must be treated simultaneously.
What Is a Dual Diagnosis?
A dual diagnosis, often referred to as co-occurring disorders, is when someone is diagnosed with a substance use disorder and some other form of mental illness. Dual diagnoses represent special occurrences ofcomorbid conditions — conditions that occur in a person at the same time.
Co-occurring disorders are very common.
Why Are Dual Diagnoses So Common?
There is a high prevalence of comorbidity between substance use disorders and other mental health disorders, all of which are formally listed in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition.
Still, the high rate of dual diagnoses associated with nearly every type of mental health disorder does not mean that one disorder caused the other, even if one condition appeared first.
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For instance, a person who develops depression and then later develops a substance use disorder should not be evaluated as someone whose experience of depression caused their substance use disorder.
There are many intervening factors that interact to produce these disorders. It is rare that an actual causal relationship occurs.
What Factors Explain the High Rate of Dual Diagnoses?
According to APA, there are three conditions that may explain the high rate of dual diagnosis. These include:
- A person experiencing one or more symptoms of another mental health disorder when using any drug of abuse
- A person having a diagnosed mental health disorder that might lead to substance abuse
- A person experiencing overlapping features of substance use disorders and other mental health disorders. For instance, similar genetic factors, similar environmental experiences, and the interaction of these features can produce any type of mental health disorder.
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Not the Result of Substance Abuse or a Medical Condition
When any type of psychiatric symptom is believed to be caused by a medical condition or the direct result of drug use, the individual cannot be diagnosed with a psychiatric disorder.
For instance, individuals who become extremely depressed during withdrawal from stimulants would not be diagnosed with depression. Instead, when it is determined that the direct effects of drug use are responsible for the particular psychiatric presentation, the individual is diagnosed with substance- or medication-induced depression.
Likewise, when a medical condition is responsible for the person’s psychiatric symptoms, they are diagnosed with a disorderdue to another medical condition. An example of this is depression due to hypothyroidism.
Thus, psychiatric symptoms that are known to be caused by the direct effects of substance use or other medical conditions are diagnosed according to the condition that caused them and not as standalone psychiatric disorders.
Nearly every psychiatric or psychological disorder in the DSM-5 is associated with an increased risk for the development of a substance use disorder.
The DSM-5 list several different categories of depressive disorders where chronic sadness or decreased mood is the main feature of the disorder.
Most people who are diagnosed with depression are actually diagnosed with major depressive disorder (MDD). This disorder is different from normal everyday fluctuations in mood and everyday sadness that individuals experience.
MDD is a diagnosable syndrome that requires specific conditions to be met. These conditions must be present for a minimum of a two-week period.
Depressive disorders are associated with high rates of substance abuse. Over 20 percent of individuals diagnosed with MDD also have a comorbid diagnosis of a substance use disorder.
The most common substance of abuse in people with MDD is alcohol, although other substances are certainly abused. Some estimates suggest that 40 percent or more of individuals diagnosed with MDD have some type of co-occurring substance abuse issue.
Bipolar disorder occurs when an individual displays alternating periods of mania or hypomania and/or depressive symptoms.
Like the depressive disorders, there are several different subtypes of bipolar disorders listed in the DSM-5. When most people are discussing bipolar disorder, which is sometimes referred to as manic depressive disorder, they are discussing bipolar I disorder. With bipolar I disorder, the individual displays manic symptoms while also displaying intermittent periods of major depressive disorder.
More than 50 percent of individuals diagnosed with bipolar 1 disorder have a co-occurring alcohol use disorder. Other substance use disorders also occur in individuals diagnosed with any type of bipolar disorder, including opioid use disorders, cannabis use disorders, and others.
An anxiety disorder is a general category of disorders where the distinguishing feature is dysfunctional anxiety. There are several major types of anxiety disorders, including panic disorder, phobias, and social anxiety disorder.
Anxiety disorders are commonly comorbid with alcohol use disorders. Nearly 20 percent of individuals diagnosed with an anxiety disorder will have a co-occurring substance use disorder.
The major types of eating disorders are anorexia, bulimia, and binge eating disorder.
Eating disorders are commonly comorbid with substance use disorders. Individuals with anorexia are less likely to have a co-occurring substance abuse issue than individuals with bulimia or binge eating disorder.
Alcohol is the most common substance of abuse in people with eating disorders, but other substances are also abused, such as amphetamine or tobacco to control weight.
The obsessive-compulsive disorders include obsessive-compulsive disorder (OCD), hoarding disorder, and several others. These disorders were once diagnosed as different types of anxiety disorders because it was believed that anxiety was the dominant feature of the disorder, but now, they are diagnosed in their own category.
The primary feature of these disorders is the presence of obsessions (intrusive, repetitive, and unrealistic thoughts or beliefs) and compulsions (repetitive behaviors designed to reduce the anxiety associated with the obsession).
Research has suggested that 20 to 30 percent of individuals who are diagnosed with OCD have a co-occurring substance abuse issue.
There is also evidence to suggest that the particular type of substance abuse that is comorbid with OCD is different for men than it is for women. Men diagnosed with OCD are more likely to have an alcohol use disorder, whereas women with OCD may be more likely to abuse prescription medications.
There are high rates of alcohol use disorders and prescription medication abuse overall individuals with OCD.
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APA currently recognizes 10 different personality disorders that are divided into three separate clusters. The clusters are identified by the major driving factor of the personality disorder.
Personality disorders are very chronic, rigid, and dysfunctional approaches to dealing with others and the challenges of life in general. These disorders typically begin to appear in late childhood or early adolescence. They are often very resistant to change even if they are extremely dysfunctional.
Research studies have suggested that the type of personality disorder may influence comorbidity for a particular type of substance abuse. For instance, alcohol is the most common substance of abuse with personality disorders. Estimates suggest that 22 to 78 percent of individuals with personality disorders may have a co-occurring alcohol use disorder.
Other types of substance use disorders are also common in individuals diagnosed with personality disorders, including stimulant use disorders, prescription medication abuse, and others.
Attention Deficit Hyperactivity Disorder
Attention deficit hyperactivity disorder (ADHD) is a disorder that has three very separate and different subtypes.
- One subtype consists of individuals who primarily have difficulties paying attention but are not hyperactive.
- Another subtype consists of individuals who are hyperactive but do not have significant attentional problems.
- The third subtype consists of individuals who have both dysfunctional attention and hyperactivity.
The disorder must first appear in childhood even if it is diagnosed in an adult.
ADHD is commonly treated with medication, although contrary to popular belief, individuals with ADHD are not likely to abuse their prescribed medications.
Instead, individuals who are not treated for their ADHD are far more likely to develop issues with substance abuse than those who are formally treated.
The most common co-occurring substance use disorder in individuals with ADHD is alcohol use disorder. Other substances are commonly abused, such as tobacco and cannabis.
Schizophrenia is a severe psychiatric disorder where an individual loses contact with reality. These individuals often have hallucinations, which are most often auditory. They also suffer from delusions or very fixed, rigid, and unusual beliefs. They frequently have problems expressing emotions or feeling pleasure.
The most common co-occurring substance use disorder in individuals diagnosed with schizophrenia is a tobacco use disorder. It is estimated that nearly 70 to 80 percent of individuals diagnosed with schizophrenia engage in the abuse of tobacco products.
It may be that the nicotine in cigarettes has a medicinal effect on the distress associated with schizophrenia.
Other common substances of abuse include alcohol, prescription medications, and illicit drugs like heroin or cocaine.
As mentioned above, nearly every psychological or psychiatric disorder listed in the DSM-5 is associated with an increased risk of developing a substance abuse issue.
Some disorders, such as autistic spectrum disorders, have far less risk for the development of a substance abuse issue. However, any form of mental illness is associated with an increased risk to develop a substance abuse issue and to be given a dual diagnosis
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Treatment for individuals with dual diagnoses should be comprehensive. It should simultaneously address all of the individual’s psychological or psychiatric conditions. Trying to treat the substance abuse issue without addressing the other co-occurring issue is never an effective approach.
Typically, this is described as an integrated treatment approach. This approach utilizes a team of specialists from different fields who work together to address all the individual’s issues simultaneously.
The team is typically led by a psychiatrist or other physician. The members of the team meet periodically to discuss treatment progress and further develop the overall treatment plan.
Treatment for dual diagnoses will typically combine therapy with medication and other treatment interventions that are deemed necessary for the individual’s recovery.
The types of behavioral interventions that are typically useful in the treatment of dual diagnoses include:
Different types of cognitive behavioral therapy (CBT) that address dysfunctional belief systems and behaviors. There are many different types of CBT that are used in the treatment of dual diagnoses, such as dialectical behavior therapy, systematic desensitization, rational emotive therapy, and others.
These are often useful for individuals with severe dysfunction, such as schizophrenia. These programs provide rewards or vouchers when the individual practices healthy behaviors.
These long-term residential treatment programs help individuals learn to function in a protected environment.
This provides outreach services to individuals in the community.
These exist for many different types of substance use disorders —Alcoholics Anonymous, Narcotics Anonymous, and many others. They also exist for specific types of mental health disorders.
Medications are often used in the treatment of dual diagnoses. The medications can be used to treat the specific disorder in question and to address issues with substance abuse, such as withdrawal symptoms or cravings.
Research indicates that the combination of medications and behavioral treatments like therapy and group support is more effective than using either treatment alone.
The approach to treating individuals with dual diagnoses is long term. In cases like schizophrenia co-occurring with substance abuse, it may be indefinite.
Long-term participation in therapy and peer support groups is often needed to maintain abstinence from drugs or alcohol and to continue to address the issues particular to the psychological diagnosis.
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