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Article Summary

A Guide To Dual Diagnosis

A drug or alcohol addiction is often accompanied by other conditions. As such, most addicts hardly ever choose to continue using alcohol and other substances without reason. In many cases, pre-existing mental health conditions cause, contribute to or exacerbate the addiction.

Conversely, the consumption of alcohol and drugs can also contribute to, worsen, or cause new psychological conditions. When mental illness and substance addiction exist at the same time, medics refer to it as a co-occurring disorder or a dual diagnosis.

If you struggle with this type of disorder, you might require specialized care as administered by trained, qualified, and experienced professionals before you can be considered to be fully healed.

As such, it is quite common for people seeking addiction treatment to discover that they also suffer from a co-occurring psychological/psychiatric disorder. In fact, poor mental health might coexist with substance abuse and addiction for several years before you discover that there is more to your addiction that the simple physical dependence on drugs and alcohol.

Unless doctors treat the underlying mental health issue alongside your addiction disorder, it is highly likely that your chances for long term recovery remain poor at best. In fact, the NIH (National Institutes of Health) estimates that people with depression or anxiety disorder are 50% more likely than those without similar conditions to abuse alcohol and drugs. Additionally, individuals suffering severe mental illnesses such as schizoaffective disorder (with psychotic features) and schizophrenia will also experience higher rates of substance abuse and addiction than those in the general population.

To this end, as you undergo assessment for addiction, you might have to meet with a mental health professional. This expert will use several diagnostic tools to determine whether you also suffer from a co-occurring psychiatric disorder. If they find that mental illness and alcohol or drug addiction coexist, the condition will be referred to as a dual diagnosis.

What Is Dual Diagnosis?

Treatment for dual diagnosis is relatively new in the field of substance addiction recovery. In fact, until the 90s, people who suffered the typical symptoms of poor mental health - mood swings, delusional behavior, depressive episodes, and anxiety attacks, among others - received treatment separate from those seeking help for alcohol and drug abuse.

Where these conditions were found to be overlapping, the client would be denied treatment for mental illness until after they had sobered up and cleaned their bodies of the drugs/alcohol.

Unfortunately, since recent research has discovered that substance abuse is sometimes driven by underlying psychiatric disorders, it follows that many people suffering from the dual diagnosis of poor mental health and addiction never received the help that would have saved them.

That said, the relationship between mental illness and substance abuse is now understood to be more complex than previously assumed. In fact, these two conditions might be related in any or all of the ways listed below:

  • Heavy alcohol or drug use might precipitate poor mental health by damaging the brain or altering the chemical balance in the brain
  • Poor mental health might predispose you to use drugs or drink more alcohol as a strategy to escape your psychiatric symptoms or relieve them
  • The psychiatric effects of substance use and abuse (including anxiety, mood swings, mania, and depression) often resemble poor mental health
  • The symptoms of poor mental health often resemble the side effects arising from regular substance abuse and eventual addiction

For treatment, skilled therapists are highly likely to assess you on multiple levels to uncover the relationship between your substance abuse and mental health. However, even highly experienced experts have a challenging time making a dual diagnosis.

Although the symptoms of one disorder might predate those from the other, both disorders are highly likely to exacerbate each other. This usually makes it close to impossible for medics to extricate and differentiate the symptoms of one condition from the other.

For instance, if you try to escape the symptoms of your depression as caused by personality or mood disorder by shooting heroin or taking prescription pills, you might eventually discover that although this self-medication is effective a couple of times, you might eventually start struggling with (on top of your depression symptoms) the following:

  • Cravings for your drug of choice
  • Tolerance for the drug you have been using, leading you to require higher doses
  • Increased episodes of exacerbated poor mental health signs and symptoms
  • Longer lasting or more intensive poor mental health symptoms
  • Serious withdrawal symptoms
  • Addiction

Understanding Concurrent Disorders

Otherwise referred to as dual diagnosis, concurrent disorders (or double trouble in layman's terms) are used to define the combination of substance abuse and mental health issues).

Instances of concurrent disorders include clinical depression or PTSD and alcohol addiction, cocaine addiction and ADHD, Benzodiazepine dependency and Generalized Anxiety Disorder.

In many cases, it is often close to impossible for the medics to separate addiction and poor mental health because most doctors tend to misdiagnose addiction and/or confuse the accompanying symptoms.

It is due to this that many clients are only able to enjoy normality and mental stability after their addiction has been addressed. As a direct result, substance abuse is now thought of as a self-medication condition, which often carries the following mental and emotional disorders:

  • Anxiety
  • Bipolar Disorders
  • Depression
  • Mood Disorders
  • Panic Disorders
  • Personality Disorders
  • Psychosis
  • Schizophrenia

Also, it is common for individuals suffering from poor mental health to start using illicit and addictive substances to improve their ability to cope, feel better, or numb and decrease their feelings.

Of course, self-medication might work in the first few days or weeks, and provide you with relief from your excited brain. However, the problems and pain might start getting out of control, and the drugs/alcohol will only make your issues worse than they were before.

As you might already imagine or even have experienced, the links between substance abuse and poor mental health are manifold. Consider the following:

a) Family History

A family history of either substance abuse or mental illness might translate into genetic susceptibility and vulnerability to drug and alcohol use and/or poor mental health.

b) Adverse Childhood Events

In the same way, recent research shows that adverse childhood events - including childhood emotional, physical, and sexual abuse - might predispose you to substance use problems and/or mental health issues in your adulthood.

c) Use

Similarly, extensive or prolonged substance use and abuse might mask, mimic, exacerbate, or cause mental health signs and symptoms. The poor mental health caused by heavy substance use will typically go away once you achieve sobriety. However, your vulnerability for poor mental health might persist.

As a direct result, mental health issues arising from persistent substance abuse are typically referred to as substance-induced mental health disorders. For instance, if you binge on cocaine, it is highly likely that you will start suffering depression-like symptoms. In this case, you will have a difficult time getting out of bed for around 5 days after you abuse the substance.

In the same way, medics have discovered that substances often exacerbate or compound mental health symptoms. For instance, alcohol acts to depress the central nervous system, thereby sedating or slowing down nervous system functioning. In this way, it will often worsen already existing depressive-symptoms, such as lack of motivation or hypersomnia.

Not surprisingly, substance abuse often tends to cause instability with regards to sleep, motivation, mental functioning, physical energy, and mood - areas that are all impacted by poor mental health.

As a direct result, it is common for substance abusers to experience inaccurate mental health diagnosis - with some being diagnosed with bipolar disorder. Similarly, some symptoms apply to both substance abuse and poor mental health - such as problems concentrating or focusing, and insomnia.

Consequently, it might be difficult to ascertain if the symptoms reported stem from the addiction or they are a reflection of the mental health difficulties the substance abuser is suffering.

Still, mental health issues tend to increase the vulnerability of the brain to the harmful effects of regular and heavy alcohol and drug abuse. According to the Super Sensitivity Model, the brain of individuals suffering from poor mental health are more negatively and more strongly impacted by even the most minor amounts of drugs and alcohol as compared to people without existing mental health issues.

Drug and alcohol dependency might also make it even harder for you to recover fully from such mental illnesses as anxiety and depression which interfere with your adherence and commitment to treatment (including the attendance of counseling and medical appointments or the taking of the medications prescribed). Further, it might impact your ability to learn the coping skills required to counter any mental health symptoms you are suffering from.

Overall, mental health issues are likely to interfere with your day to day functioning with regards to relationships, leisure, general productivity, and work. As a direct result, these issues might cause significant problems in these basic areas of ordinary functioning.

When such difficulties persist for long, you are more likely to seek some relief or escape by consuming addictive substances and alcohol. Consequently, the route to addiction might innocently start with your night caps to help with insomnia as caused by depression and anxiety.

Eventually, relapses in the poor mental health symptoms might prove concurrent relapses into regular substance alcohol abuse - and vice versa. Therefore, it is important to understand the complex interaction between substance and mental health problems. These interactions are likely to change the outcome and the course of the problems you end up experiencing.

Signs And Symptoms Of Co-Occurring Disorders

For an official dual diagnosis, it is imperative that you get evaluated by an addiction specialist or a mental health professional. However, you most certainly do not have to be a qualified primary care doctor or a psychologist to be able to tell that something is off with you or with someone you love/care about.

Although there was no named condition or official term, substance abuse and mental illness have been closely linked for several years. As such, dual diagnosis ranges from those who abuse drugs and alcohol to cope with pre-existing mental health problems to those who develop poor mental health after using specific drugs and alcohol over a long period.

Irrespective of the reasons given for substance use, it is now conclusively proven that alcohol and drugs only make the symptoms of psychiatric and psychological illnesses worse. They might even lead to the development of new mental health issues.

Since both addiction and mental illness affect the brain, it is not surprising that these conditions feed off each other. When one exists, it is highly likely that the other will occur.

That said, dual diagnosis symptoms vary widely because there is a virtually endless list of possible combinations. According to NAMI (National Alliance on Mental Illness), some symptoms typically characterize dual diagnosis:

  • Abandoning family and friends in favor of a new crowd or new activities
  • Avoiding social events, former hobbies, and family activities due to your substance abuse
  • Continued substance use even after you realize that the behavior has started causing social, physical, or psychological problems
  • Engaging in risky behavior when you are under the influence
  • Expressing feelings of regret or guilt about the compulsive behavior
  • Feeling like you need alcohol or drugs to function normally
  • Inability to manage responsibilities at home or at work
  • Inability to quit using the drug or choice, or to cut down on your use
  • Loss of control over your use and abuse of the substance
  • Ongoing interpersonal issues caused by the typical effects of regular chronic alcohol and drug use
  • Repeated use of alcohol and drugs such that it becomes dangerous (such as driving under the influence)
  • Severe cravings for the substance
  • Sleeping in the daytime and staying up late during the night
  • Spending an inordinate amount of time looking for the drug, being drunk or high, or recovering from your use
  • Stealing or lying to continue your addictive behavior
  • Sudden, unexpected changes in behavior
  • Taking more of the substance than you intended
  • Tolerance for your drug of choice, meaning that you will need higher doses to experience the desired effects
  • Trying to quit having unsafe sex, gambling, drinking, or using drugs but finding yourself relapsing
  • Withdrawal from family and friends
  • Withdrawal symptoms when you go without your drug or alcohol of choice

You can only know for certain whether you suffer from dual diagnosis by consulting addiction treatment specialists with a background in serious psychiatric care. At the dual diagnosis rehabilitation facility where you are likely to be referred, evaluation specialists and intake counselors will also review your substance use patterns and check your psychiatric history before coming up with an individualized treatment plan for you.

The hardest part about getting support is reaching out for help. However, once you do, the right medics will come to your aid, and you will soon be on your way to full sobriety and recovery.

Assessments And Tests For Dual Diagnosis

For a dual diagnosis to be made, it is imperative that you meet the criteria set for mental health disorders as stipulated by the DSM (Diagnostic and Statistical Manual of Mental Disorders). The DSM is published by the APA (American Psychiatric Association) as a guideline that mental health professionals can use while diagnosing and treating patients in various clinical settings.

A therapist, counselor, psychologist, physician, or psychiatrist is qualified to provide a dual diagnosis to patients suffering from an addiction to alcohol, drugs, or certain behaviors (gambling, sex, and the like) accompanied by a mental health disorder.

If you get a dual diagnosis, it might come as a relief especially if you have been living with undiagnosed mental health issues over an extended period. If you have had to put up with flashbacks to traumatic life events, hallucinations, suicidal thoughts, episodes of sadness and hopelessness, and severe mood swings, putting a name to the condition is likely to provide you with a sense of hope. Once that is done, you would be in a better position to receive treatment and recover.

However, recovery from poor mental health tends to be more challenging for people who are also battling addiction. However, with a compassionate and properly trained team, you should be able to make it through detoxification and rehabilitation and get started on your journey to full recovery.

Through dual diagnosis assessment, the medics will focus on psychological assessment and cognitive evaluation. The screening tools used might take the form of computer games, structured questionnaires, and standardized multiple choice tests. Some of the tests may provide question sets that the therapist will ask during the face to face interview while others will be provided as written exams.

To improve the accuracy of the results, the therapists are likely to administer the tests in a setting that is private, comfortable and quest. Addiction Science and Clinical Practice asserts that such standardized diagnostic instruments are effective because they allow practitioners to develop actionable treatment plans based on research that is based on empirical evidence.

Consider the following:

1. Diagnostic Criteria

The diagnostic criteria for most of the screening tools might be based on standards established by the DSM-V (Diagnostic and Statistical Manual of Mental Disorders), a reference book by the APA (American Psychiatric Association).

Today, the DSM-V is widely recognized as the foundational source of classification of poor mental health within the psychiatric community.

2. Cognitive Function Tests

The therapists might also use cognitive function tests, which are widely accepted as the norm in evaluating the cognitive function for dual diagnosis. These tests include:

  • Differential Abilities Scale (DAS-II)
  • Halstead-Reitan Neuropsychological Battery
  • Mini-Mental State Exam (MMSE)
  • Stanford-Binet Intelligence Scales
  • Test of Variable Attention for ADD/ADHD (TOVA-8)
  • Wechsler Adult Intelligence Scale (WAIS-IV)
  • Woodcock-Johnson Tests of Cognitive Abilities III

Cognitive testing is useful in the identification of those conditions that are known to affect intellectual function - such as ADHD (attention deficit hyperactivity disorder), brain injury, dementia, and learning disorders. These conditions can negatively affect judgment and impulse control, thereby predisposing you to addictive behavior and tendencies.

3. Psychological Tests

Similarly, therapists and medics rely on psychological tests to distinguish between the symptoms of psychiatric disorders and the side effects of drug and alcohol addiction. These tests are also useful at providing medics with the information required to develop the client's personality profile. Some of the tools popularly used for assessing personality and psychiatric disorders include but are not limited to:

  • Beck Anxiety Inventory
  • Beck Depression Inventory (BDI-II)
  • Brief Psychiatric Rating Scale
  • Comprehensive Psychopathological Rating Scale (CPRS)
  • Depression Anxiety Stress Scales (DASS)
  • Hamilton Rating Scale for Depression
  • Million Clinical Multiaxial Inventory (MCMI)
  • Minnesota Multiphasic Personality Inventory (MMPI-II)
  • Myers Briggs Type Indicator (MBTI)
  • Rorschach Inkblot Test
  • Young Mania Rating Scale (YMRS)
4. Testing for Co-occurring Conditions and Addiction

Apart from psychological and cognitive testing, the therapist is likely to assess you to check the severity of your substance abuse and addiction. Some of the tools commonly used to screen for addictive behavior include:

  • Addiction Severity Index (ASI)
  • Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS)
  • CAGE Questionnaire
  • Composite International Diagnostic Interview (CIDI)
  • Psychiatric Research Interview for Substance and Mental Disorders (PRISM-IV)
  • Semi-Structured Assessment for Drug Dependence and Alcoholism (SSADDA)
  • Structured Clinical Interview for DSM-IV II

The Psychiatric Research Interview for Substance and Mental Disorders (commonly abbreviated as PRISM-IV) targets specific co-occurring disorder. This structured interview is designed to help the therapist identify certain psychiatric disorders among those who abuse alcohol and drugs.

The interview was developed so that practitioners would be able to distinguish between the side effects of substance addiction and the symptoms of poor mental health. The AJP (American Journal of Psychiatry), PRISM-IV is reliable in the identification of certain disorders in addicts and substance abusers.

5. Tests for Specific Disorders

There are many other diagnostic tools that addiction treatment specialists and mental health practitioners can use for dual diagnosis. Most of these tools are designed to identify specific disorders and target certain populations. They include, but are not limited to:

  • Angst Hypomania Checklist (AHCL)
  • Autism Diagnostic Observation Schedule (ADOS)
  • Dissociative Experiences Scale
  • Eating Disorder Inventory
  • Geriatric Depression Scale (GDS)
  • Juvenile Bipolar Questionnaire
  • Leyton Obsessional Inventory
  • Positive and Negative Syndrome Scale (PANS)
  • Posttraumatic Stress Diagnostic Scale (PDS)
6. Social Anxiety Scale

Last but not least, therapists who specialize in dual diagnosis might apply a wide variety of tests based on your emotional effect, self-reported symptoms, substance abuse history, age, and other factors. Additionally, they will use their observational skills and clinical training to develop comprehensive client profiles showing your neuropsychological status.

Integrated Treatment Options

Living with addiction alongside poor mental health is one of the deadliest of combinations. The poor lifestyle choices you are likely to make on account of these two disorders will often translate into sudden or early death for you if you don't receive due treatment.

Some of the life-threatening issues commonly co-occurring with poor mental health include:

  • Asthma
  • Diabetes
  • Heart disease
  • Obesity
  • Smoking

To this end, addressing the disorders that are likely to contribute to poor lifestyle choices that might hasten early death is crucial for anyone living with a co-occurring disorder.

Through integrative treatment, you will receive the complete range of treatment services you need, thereby getting everything needed to help you heal at every level. The specific services vary depending on your needs, but might also include resources to help you make certain lifestyle changes. Others will be directed at mental health and addiction treatment.

Additionally, the integrated treatment program is likely to recommend certain lifestyle changes to promote your wellness and health. These changes include:

  • Addressing all chronic medical conditions
  • Addressing work-related issues and job skills
  • Improving your communication skills
  • Improving your eating and nutritional behaviors
  • Improving your sleep habits
  • Managing legal issues, if any
  • Working on your family relationships

Through these changes, you will receive everything you need to return to work, build an uniquely strong support network, rebuild your relationships at home, and start getting back on track with your life.

Integrated treatment outlines the comprehensive rehabilitation program that will offer you all the holistic, therapeutic, and medical resources you need to heal spiritually, emotionally, mentally, and physically. Irrespective of the mental health diagnosis - and especially if the issue lies with co-occurring disorders - it is highly likely that the doctors will recommend integrated care.

Due to your unique condition, the medics might also create a treatment plan that is highly personalized. Since you may be living with both a mental health disorder and a substance abuse/addiction disorder, the integrated treatment plan is likely to include the following options:

1. Medical detox

If you have been struggling with your addiction to drugs, alcohol, and other substances, the detoxification period might take place over the first few days or weeks after you cease your substance use. This period is often defined by mental and physical withdrawal symptoms.

As such, detoxification services are designed to provide you with medical monitoring and support to help you stabilize during your treatment.

2. Evaluation

The second step in integrated treatment is designed to ensure that all the mental health symptoms you suffer are diagnosed accurately. During this evaluation, the therapists will also identify all the other issues that might act as a hindrance on your path to full recovery.

3. Diagnosis

Based on the experience you reported and the results from your evaluation, the medics might also make diagnoses to improve your understanding of past experiences and frame them while planning for the future.

4. Treatment Plan

Next up, the medics may create an unique treatment plan. This plan is highly likely to integrate a wide variety of medical and therapeutic interventions. The goal of the integrated treatment would be to empower you to start healing from your addiction. You will also learn how to address any problematic personal issues and manage your mental health symptoms.

5. Personal Therapy

The foundation of full recovery after a dual diagnosis often like on face to face therapy. By undertaking one-on-one therapy, you will have a confidential and safe forum in which you can discuss current issues, past experiences, goals for your future, and the changes happen to you during therapy.

As you achieve different treatment goals based on your initial treatment plan, you might also work together with your therapist to formulate new goals while adjusting your current treatment plan accordingly.

6. Group Therapy

You may also join different types of groups as part of your integrated treatment program after a dual diagnosis. These groups include the following:

  • 12-step groups
  • Groups focusing on certain aspects of drug and alcohol addiction
  • Groups where participants deal with commonly shared life issues, such as job seeking, legal problems, and parenting issues
  • Support groups for those suffering from the same mental health conditions
7. Family Therapy

During your treatment, you might get the opportunity to work together with your loved ones to rebuild the relations you damaged when you were suffering from untreated poor mental health and addiction.

During family therapy, you will improve your chances of recovery especially if you plan on returning home to continue with your family after you undergo treatment and come out healed.

By empowering your family members, you might be able to ensure that they connect with the treatment. As a direct result, they are highly likely to start healing in their own way while also striving to help everyone in the group learn more positive communication skills.

8. Aftercare Plan

Before you leave treatment after the dual diagnosis, you are highly encouraged to continue working with your therapist to formulate a personalized after care plan. Similar to the treatment plan, your aftercare plan should include a wide mix of treatment services designed to serve your treatment needs and goals albeit on an outpatient basis.

The aftercare treatment will help you both during and after you start transitioning to independent living after you recover.

9. Aftercare Services and Support

Last but not least, seeking integrated treatment for your co-occurring disorders means that you should create an unique integrated aftercare plan. This plan should incorporate all the services that will address your treatment needs until you recover fully.

Similarly, the therapist will recommend continued mental health care and support building as you recover from addiction and poor mental health. Finally, you might end up continuing with the personal therapy and alternative and holistic therapies that worked for you during treatment.

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