Dual Diagnosis with Addiction
What is Dual Diagnosis?
Dual diagnosis is a term doctors use when a person struggles with a substance use disorder and a mental illness. Sometimes, doctors also call this condition a co-occurring disorder.1
An estimated 9.2 million people in the United States have a dual diagnosis, according to the National Alliance on Mental Illness (NAMI).2
The conditions that occur with dual diagnosis can range in severity from mild to severe. Some of the symptoms of a dual diagnosis include:3
Avoiding social activities with family and friends
Experiencing withdrawal symptoms when they aren’t using, such as in the morning or early afternoon
Losing control over how much and how often a person uses a particular substance
Problems thinking/problems concentrating
Sudden, unexplained changes in behavior
Withdrawing from family and friends
One of the reasons why a person with a dual diagnosis needs to recognize symptoms of both conditions is that one can contribute to the other. One of the reasons why it’s important to identify a dual diagnosis is to recognize symptoms of both conditions and how they can contribute to the other. If both the substance use disorder and mental health concerns aren’t addressed at the same time, they are less likely to recover for the long-term and improve the overall quality of life.
Dual Diagnosis by the Numbers
Nearly one-third of all people who struggle with addiction also have a mental illness, according to NAMI.4
An estimated 21 million Americans struggle with a substance use disorder. Of those, an estimated 8 million also have a dual diagnosis with a mental illness.5
These statistics mean that a person with a mental illness is twice as likely to struggle with substance abuse than a person who does not. According to NAMI, a person with mental illness: 6
Consume 38% of all alcohol
Use 44% of all cocaine
Use more than half all opioid prescriptions
As a general rule, the more severe a mental illness is (such as having a condition like bipolar disorder or schizophrenia), the more likely it is for that person to also have a substance use disorder. 7
Having a doctor know about a dual diagnosis is important on many levels. First, doctors know that a dual diagnosis can make both conditions more challenging to treat. Second, those who struggle with a dual diagnosis may need more intense care, such as staying at an inpatient treatment facility. In some instances, inpatient treatment can help support safety as some conditions can cause hallucinations, suicidal thoughts, and thoughts of self-harm.
Dual Diagnosis Conditions that Commonly Co-Occur with Substance Use Disorder
Doctors don’t really know why some people struggle with a dual diagnosis, and others do not. They do have a theory that some people use substances as a means of self-medication. This means they drink or take sedatives or painkillers to try and block out sad, repetitive, or otherwise harmful thoughts.8
Some people with a dual diagnosis also don’t have mental health problems until they start to abuse drugs or alcohol. Then, as a result of the substance abuse, they start to experience greater incidences of sadness, hopelessness, and other mental health concerns.
Anxiety in a Dual Diagnosis
Anxiety is a heightened sense of nervousness or fear related to a situation. A person who struggles with anxiety experiences significant levels of fear and stress related to their everyday life. Sometimes, a person may turn to substance abuse as a means to escape these feelings. According to an article in the journal Harvard Reviews in Psychiatry, struggling with anxiety and a substance use disorder causes worse symptoms, greater impairment in everyday activities, and more severe course of illness than if a person didn’t have either condition.9
An estimated 18 percent of adults in the United States have struggled with anxiety in the past year, and 29 percent of all people have struggled with anxiety across their lifetime.10 The Harvard Reviews in Psychiatry article also reports that people with anxiety disorders are most likely to abuse opioids, sedatives, and tranquilizers than those who do not.11 Sometimes, a person can experience anxiety related to withdrawals from a particular substance of abuse. However, once detox is complete they usually experience less symptoms of anxiety.12
Bipolar Disorder in a Dual Diagnosis
Bipolar disorder is a condition where a person may fluctuate between highs and low. Sometimes, a person is very depressed, with periods of mania. This is when a person feels an altered sense of hyperactivity — they don’t sleep, may go on a spending spree, or may go on a drug or alcohol “bender.”
Other people are the opposite, and spend much of their time in a manic state, only to go to a period of depression. A lot of people think if they had a serious mental health condition like bipolar disorder, that they would know it. But that isn’t totally true. A lot of people who struggle with addiction have an undiagnosed bipolar disorder, and for years, they’ve used drugs or alcohol to try and “treat” their mental health conditions, according to an article in Psychology Today.13
The Different Types of Bipolar Disorder
Different types of bipolar disorder exist. According to Psychology Today, an estimated 60.7 percent of people with bipolar I disorder also struggle with substance abuse.14 Doctors also call bipolar I disorder “manic depression.” A person with this condition has very severe mood swings. An estimated 48.1 percent of people who struggle with bipolar II disorder also struggle with substance abuse.15 Bipolar II disorder causes less-severe mood swings, but still affects a person’s overall well-being.
The Dangers of Using with Bipolar Disorder
Adding drugs or alcohol to the mix in cases of a bipolar diagnosis can severely worsen the condition. According to Psychology Today, having an alcohol use disorder causes more rapid cycling between moods and also increases the risk of violence and aggression.16 Some signs of bipolar disorder include euphoric mood following by agitation, rapid thoughts, sleeping less, having suicidal thoughts, or acting extremely impulsively, such as going on shopping sprees.17
Borderline Personality Disorder in a Dual Diagnosis
Borderline personality disorder is a medical condition where a person has a distorted sense of self. This means they can’t see things like they really are — and as a result, they may appear dramatic, manipulative, and highly co-dependent. Some people with borderline personality disorder say they feel emotionally unstable, and they have a hard time maintaining relationships with others.
Like many other mental illnesses and addiction, some people with borderline personality disorder struggle with their thoughts and behaviors. They may turn to drugs and alcohol to deal with their symptoms. However, substance abuse usually only heightens mood swings and self-destructive actions.
Codependency in a Dual Diagnosis
Codependency is an addiction itself — an addiction to being in love or with a particular person. A person can be co-dependent on a partner, family member, friend, or another person in their life. While all people in a relationship have some element of give-and-take, a codependent person takes it to the next level. Some symptoms include:
Constantly attracted to “needy” people
Find themselves doing more work in a relationship and for a person than they are capable of doing
Feeling angry and victimized, but not leaving the person
Experiencing constant feelings as if they are not good enough
Only find joy in their relationships and cannot appreciate other activities
A codependent person can easily abuse drugs and alcohol as a means to help them feel good because they often don’t feel good about themselves.
Depression in a Dual Diagnosis
Depression is more than feeling a bit sad. Those with depression struggle to get through daily activities. Depression frequently results in constantly feeling fatigued and some aches and pains may even be related to emotions.
Depression is also a common feature among other mental illnesses, including bipolar disorder and post-traumatic stress disorder. The condition is the reason why many people turn to drugs and alcohol. Also, it’s common to experience intense feelings of depression when withdrawing from a particular substance.
Obsessive-Compulsive Disorder in a Dual Diagnosis
OCD is a condition which causes a person to develop severe anxiety and preoccupation with certain thoughts and behaviors. Sometimes, these thoughts can be very unpleasant, such as thoughts of self-harm or violence. Someone dealing with ODC cannot control these thoughts and behaviors. They often feel a lot of internal torment related to these thoughts and behaviors.
Sometimes, the need to complete an action (such as obsessive hand washing) can interfere with everyday activities and may even harm physical health because of the habit. Some people turn to drug or alcohol abuse as a means to escape these thoughts — but substances don’t usually help in the long-term.
Trauma/PTSD in a Dual Diagnosis
Post-traumatic stress disorder (PTSD) and addiction are two conditions that frequently occur together. It’s not uncommon for those who have experienced a trauma, such as a military battle, natural disaster, or history of physical and sexual abuse, to turn to drugs, smoking, and alcohol as a means to escape feelings and flashbacks.18 While this isn’t always the case, some people who’ve served in the military suffer from PTSD and a substance use disorder.
According to the U.S. Department of Veteran’s Affairs, an estimated 2 out of 10 veterans with PTSD also suffer from a substance use disorder.19 Abusing drugs and alcohol is not a healthy approach to treating PTSD. In fact, it will probably make the PTSD worse. That’s why it’s important to seek treatment at a facility that can treat both conditions at the same time.
Therapies for Dual Diagnosis
Before there was more research available on dual diagnosis, rehab facilities used to treat one problem at a time. They would try and help a person overcome their drug addiction before they would treat their depression or other mental illnesses.20
However, evidence-based research suggests that treating both conditions at the same time is the best and most effective way to help address dual diagnosis, according to NAMI.
Often, a doctor may prescribe a combination of medications and therapy to help reduce the incidence of dual diagnosis symptoms. The medications prescribed depend upon any underlying condition or conditions. Medications alone aren’t usually effective in treating a condition. It’s important to also participate in therapy to learn how to deal with the thoughts, feelings, and emotions that can occur in mental illness and substance use disorders.
CBT for Dual Diagnosis
Cognitive-behavioral therapy or CBT is a therapy approach that involves providing education about the different aspects of addictive thinking and mental health. A therapist works with a person to help them see how their ways of thinking are affecting lifestyle choices and their overall sense of well-being. Then a therapist helps the person identify behaviors that can support a healthier and sober lifestyle.
Examples may include working through scenarios where a person is asked to use drugs again or what to do when a person experiences strong cravings for a drug. CBT is a common therapeutic approach to treat many medical conditions. According to an article in the journal Harvard Reviews in Psychiatry, a research study that involved CBT protocols and treating anxiety or just standard addiction treatment reported better results and reduced anxiety with the integrated approach.21
DBT for Dual Diagnosis
Dialectical behavior therapy is a form of cognitive behavior therapy that doctors commonly use to treat medical conditions like borderline personality disorder. However PTSD, eating disorders, and other mental health conditions can also benefit from this therapy approach. DBT involves “validation.” This means that a therapist helps a person discuss the way they think and feel. The therapist “validates” or helps the person identify why the way they think does or doesn’t make sense.
A lot of times, those who abuse drugs and alcohol are in denial about the feelings they have — hearing that their feelings are valid and in some ways, real, can help a person move forward and learn to accept themselves. When they do this, it’s possible to engage in healthier, more positive behaviors.
REBT for Dual Diagnosis
Rational emotive behavior therapy (REBT) is a therapy form that helps a person identify thoughts and behaviors that are negative — such as feelings of anger, depression, or guilt. A person then works to turn negative emotions into positive ones. The therapy involves making life changes, such as healthy eating, planning ahead, and relieving stress, that can help a person feel mentally and physically better.
Experiential Therapy for Dual Diagnosis
Experiential therapy is commonly used for those with PTSD. It involves allowing a person to engage in role-playing, art, music, or other forms of expression where a person can express what has happened to them in the past. Working through these thoughts and emotions can be very therapeutic.
EMDR for Dual Diagnosis
Eye movement desensitization and reprocessing (EMDR) is a technique doctors commonly use on patients who have gone through trauma and experience PTSD. To perform this exercise, a therapist asks a person to re-live all or a portion of a traumatic experience. They then direct the person’s eye movements during that time.
While this approach may sound unusual, evidence suggests that distractions or taking away someone’s attention to an event can help them process it more. They don’t usually experience as strong or severe a physical response to the event, which can help them move forward.
Motivational Interviewing for Dual Diagnosis
Motivational interviewing is a counseling technique where a therapist helps a person find their personal motivations for making changes, such as staying sober. This therapy is based on the belief that unless a person wants to make changes, they can rarely move forward.
Psychoeducational groups are group meetings that also involve some component of therapy. Sometimes, these are grouped by identifiers, such as an all-female or religious support group. Sometimes, the group is shared by people who have a similar diagnosis, such as OCD or depression.
12-step programs include options like Alcoholics Anonymous, Narcotics Anonymous, and Double Trouble in Recovery. Double Trouble in Recovery specifically is a 12-step program for people who struggle with a dual diagnosis.
Many community-, faith-, and healthcare-based groups offer support to those who struggle with mental illness and addiction.
Residential treatment to recover from a dual diagnosis involves staying at a group home or sober living home to help a person avoid relapse and start to get their life back together after rehabilitation.23 The idea of these homes is that everyone is committed to sobriety. Some homes may offer services, such as 12-step meetings or counseling services on-site.24
This option isn’t for everyone. But if a person feels like they don’t have a safe place to go home to or can’t be around others who may be using drugs and alcohol, they should seek treatment.
Holistic Therapies in Residential Treatment
Balanced whole person addiction treatment may use the following holistic therapies:
Sound bath healing
Dual Diagnosis Recovery
Dual diagnosis is a common occurrence. Both conditions can worsen the other and may require more intensive treatment or additional therapy approaches to help a person live better and experience more positive results.
Never feel ashamed of a dual diagnosis — it is a part of your experience, and you can live a better, healthier life with time and treatment.