Dual Diagnosis in Addiction Treatment
What is Dual Diagnosis?
A dual diagnosis is when a person is diagnosed with two conditions, frequently appearing as a mental illness as well as a substance abuse disorder. 1 Doctors also call this condition a co-occurring disorder.
Examples of mental health conditions that can take place with a dual diagnosis include depression, anxiety, post-traumatic stress disorder, and obsessive-compulsive disorder.
Sometimes, when a person thinks back about their substance abuse history, they find they had struggled with a mental illness and started using drugs or alcohol as a means of self-medication. They may also use substances as a means to escape their thoughts. However, drugs and alcohol almost always worsen a person’s mental health conditions and can also complicate a person’s recovery.
Other times, the opposite course is true. A person may start abusing drugs or alcohol and find they experience a deep depression or anxiety related to their addiction. Whatever the reason, having a dual diagnosis can make treatment and recovery more difficult, but certainly not impossible.
Statistics About Dual Diagnosis
An estimated 9.2 million people in the United States have a dual diagnosis, according to 2018 estimates from the National Survey on Drug Use and Health.
Having a dual diagnosis can have the following effects on a person:
More significant mental health symptoms compared to a person that doesn’t have a dual diagnosis
Greater likelihood a person whon’t stay on their medications
Increased risks for aggressive and sometimes violent behaviors
Higher incidence for emergency room visits
Greater occurrence of psychiatric placements
Researchers estimate that 21 million people in the United States have a substance abuse disorder. 2 Of these 21 million, an estimated 8 million people have a dual diagnosis with a mental illness as well. A person with mental illness is twice as likely to engage in substance abuse as a person who doesn’t have a mental illness.
According to the National Alliance on Mental Illness (NAMI), the more severe a person’s mental illness symptoms are, the more likely it is they will use illegal substances or use legal substances in an illegal manner.
NAMI reports a person with a mental illness in the United States:
- Consumes 38% of all alchol 38% 38%
- Uses 44% of all cocaine 44% 44%
Abuses more than half the opioid prescriptions
This data shows a strong relationship between substance abuse and mental illness.
Diagnoses that Co-Occur with Substance Abuse
A dual diagnosis can be any combination of mental health disorder and substance abuse. There is a spectrum of mental health disorders, some of which can completely debilitate a person and keep them from performing everyday activities or interacting with the world. Other mental health disorders may not be so obvious to a person on the outside looking in.
Examples of disorders that can co-occur with substance abuse include the following:
Anger can cause a person to deal with chronic episodes of hostility, harmful thoughts, impulsive behaviors, and aggressive tendencies toward others. Sometimes, a person with anger issues will attack other people, animals, or objects due to their anger.
Doctors have identified a condition called intermittent explosive disorder where the person has sudden episodes of violent and aggressive behavior or angry outbursts that don’t match the situation a person is getting upset about. 3 Examples of intermittent explosive disorder include road rage, domestic disputes, or breaking objects out of anger.
Just because a person has intermittent explosive disorder, their behavior is not okay or validated. It can cause the person and those around them significant distress as well as legal and financial problems.
Anxiety causes a person to experience excessive amounts of fear and worry on a regular basis. 4 If a person has anxiety on most days of the week for a period of six months or more, doctors usually call this generalized anxiety disorder.
Symptoms of anxiety include:
Sometimes, a person with anxiety will also experience social anxiety, such as fear or embarrassment when in public situations. Others will experience panic disorder, where they have panic attacks due to excess anxiety and worry.
Bipolar disorder is a mental health condition that occurs when a person fluctuates between the extremes of a personality. Doctors also call this manic-depressive disorder. A person may have time periods where they feel extremely “up” and energetic to the point where they may not sleep for several days (mania). They may then experience extended periods of depression or hopelessness where they are very down.
This condition can greatly interfere with a person’s overall health and daily well-being because they cannot control or predict how they will feel from day to day. Some days they may be so low or so high that they cannot function to interact with others or perform daily activities meaningfully.
Borderline Personality Disorder
Borderline personality disorder is a mental illness that occurs when a person has fluctuating moods and behaviors that interfere with how they think about themselves and how they maintain relationships with others.
This can cause symptoms that include:
Shifting feeligns about people constantly, such that they are a person’s best friend one day, and the next their worst enemy
Extreme fears of abandonment in relationships, such that a person will engage in extreme efforts to avoid feeling abandoned
Unstable self-image, such as a person sees themselves as very good or very bad from one day to the next
Intense and rapidly changing moods
A person with borderline personality disorder may think a loved one is abandoning them forever when they are just going on a trip for work. These constant thoughts and fears related to abandonment can make it very difficult for those around a person to interact with them.
Impulse Control Disorder
Impulse control disorder occurs when a person has great difficulty resisting a thought, behavior, or urges. They may be more prone to abuse substances because they act quickly about what they want instead of thinking about what could be harmful to themselves or others. People with impulse control disorder may easily offend others because they will blurt out the first things they are thinking without taking into consideration another person’s feelings.
Impulsive control disorder can also cause a person to find themselves in potentially dangerous and harmful situations, such as thrill-seeking. Examples of impulse control disorders include pathological gambling, kleptomania (stealing), and pyromania (setting things on fire).
Doctors also call co-dependency a “relationship addiction” because a person is addicted to a relationship with another person that is often one-sided, abusive, or destructive. Co-dependency is unfortunately common in dual diagnosis because one partner may struggle with substance abuse and have a partner who is co-dependent on them. The non-substance abusing partner may overcompensate by acting as both the mother and father to children, constantly taking care of the partner, or constantly ignoring or even validating the other person’s bad behaviors.
Often, those who are co-dependent have low self-esteem and often do not believe they are deserving of a better relationship or a person who treats them fairly.
Depression is a medical condition that leads to severe feelings of grief, helplessness, and hopelessness. The condition usually causes a person to feel this way for most days of the week for a time period of several weeks or more. Depression is a medical illness, and can even cause a person to experience thoughts of self-harm and suicide.
Symptoms that occur with depression include:
Feelings of guilt and worthlessness
Lack of interest in activities a person used ot enjoy once
Some people may also have physical aches and pains as well as problems sleeping too little or too much related to their depression.
Grief is an intense feeling of sadness and loss. This is often due to a death of a loved one, chronic illness, or loss of a job or relationship. Grief can be an overwhelming experience that affects a person’s ability to move through their daily life.
While grief is a normal part of life, for some people, it can become their norm. They have difficulty feeling any emotions other than intense sadness. As a result, they may turn to substance abuse as a means to try and escape their thoughts and feelings.
Narcissistic Personality Disorder
A person with narcissistic personality disorder has exaggerated views of themselves and their importance. They do not usually have empathy or sympathy toward others and experience a constant need or desire to feel wanted and admired. This can significantly affect their ability to have a healthy relationship with another person.
A person with narcissistic personality disorder may have a hard time feeling happy because nothing will truly make them happy. They will never get enough admiration, favors, or love because they don’t have realistic perceptions of what those attributes should be. This leads to constant feelings of feeling unfulfilled and unhappy.
Obsessive Compulsive Disorder
Obsessive-compulsive disorder (OCD) is a condition where a person has repeated, unwanted thoughts or compulsions to do things repeatedly.
Examples of some obsessions and compulsions related to this condition include:
Fear of contamination from dirt or germs
Excessive concern with order or symmetry, such as having objects arranged in a perfect line or with a certain number of objects
An urge to hoard or build up a number of possessions
Frequent cheching and re-checking of something, such as a door lock or lights
Having to wash hands hundreds of times a day
These obsessions and compulsions can completely overtake a person’s life. They may turn to drugs and alcohol as a means to try and escape.
Post-traumatic stress disorder (PTSD) is a condition that occurs after a person has experienced a trauma.
Examples of trauma that can result in PTSD:
Witness to war or torture
Victim of an accident or natural disaster
Diagnosis with a life-threatening illness
Those who are in the military, police, and emergency personnel positions are more likely to have PTSD.
One of the major symptoms of PTSD is continually re-experiencing the traumatic experience. This can result in flashbacks. A person may also constantly see or hear reminders of the time, which trigger intense emotions and feelings of fear, worry, and terror.
Dual Diagnosis Programs
According to the National Alliance on Mental Illness (NAMI), the best treatment for dual diagnosis is one that treats both a person’s mental illness and substance abuse at the same time. Some medical professionals used to refuse to treat a patient for a psychological condition until they stopped their substance abuse. Today, research has revealed this is an outdated and less-effective approach than treating both conditions at the same time.
Inpatient Drug Rehab
Inpatient drug rehabilitation is when a person stays on-site at a medical or rehabilitation facility. Addiction experts often recommend this approach when a person has a severe mental illness (such as schizophrenia or bipolar disorder). A person will usually participate in inpatient drug rehabilitation for up to seven days.
Sometimes, a person will go through detoxification or withdrawals during this time. At a medical facility or drug rehabilitation center, doctors on-site can give medications that may help reduce a person’s withdrawal symptoms.
Partial Hospitalization ProgramsPartial hospitalization is when a person remains at their home, yet goes to a drug rehabilitation facility during the daytime to receive treatments and participate in therapy sessions to support their recovery. Sometimes, a person will enter a partial hospitalization program after their inpatient program. Other times, a partial hospitalization program will be their first treatment source.
Dual Diagnosis Therapies
The following are examples of therapeutic approaches a therapist and treatment center may use to help treat dual diagnosis. The variety of treatments available shows there is no one “right” approach to dual diagnosis treatment, but instead a variety of different options that may help a person live better with their conditions.
CBTCognitive-behavioral therapy is a therapeutic approach that involves helping a person identify how the way they think about something (such as their drug use or lifestyle) can frame the way they act. Doctors commonly use cognitive-behavioral therapy to then help a person identify ways they can change their behaviors to more positive ones and resist drug abuse.
Dialectical behavior therapy (DBT) is a method used to treat patients who exhibit suicidal and other self-destructive behaviors. It is a form of CBT that can help a person better cope with stress and how to improve their relationships with friends and family. This therapeutic approach also has an element of conflict resolution.
Medication-assisted treatment is an approach often utilized with CBT or other types of talk therapy. It involves a person taking medications that reduce the withdrawal effects and cravings for drugs or alcohol as a means to help the person stay sober. MAT isn’t available for all types of substance abuse, but it is commonly used for opioid addiction and alcohol addiction.
Rational emotive behavioral therapy (REBT) is a type of CBT that helps a person identify irrational ways of thinking that aren’t logical. An example could be unhealthy eating or aggression. A therapist will help a person identify why these behaviors are harmful to the person and their well-being.
Traumatic incident reduction (TIR) therapy is an approach that involves helping a person move past significant trauma. This therapy type is a good fit for those with PTSD. The therapy involves a person confronting the trauma and learning how to develop a sense of detachment from it, so it no longer feels so negative in a person’s life, but more of a void. Ideally, a person will start to feel calmer and more at peace after this therapy.
MI for dual diagnosis
Motivational interviewing (MI) is a one-on-one therapy where a therapist helps an individual find their personal motivations for quitting substance abuse or for learning to better deal with stress and conflict. When a person is more self-motivated, they are ideally readier to take on the challenge of achieving sobriety and remaining sober.
Healing from Dual Diagnosis
Dual diagnosis is a common disorder among those who struggle with addiction and substance abuse. It’s important for a person to remember that substances aren’t a treatment for their abuse and that after some time, a person’s escape can become their prison. Through seeking positive, evidence-based treatments that tackle both substance abuse and mental health disorders simultaneously, a person can ideally start to live a healthier, fuller life.