The term “dual diagnosis” refers to having both a substance abuse disorder and a mental health condition. This is sometimes referred to as co-occurring disorders. Struggling with a mental health condition can be difficult, especially in terms of working, raising a family, going to school, or maintaining relationships with friends. Living with mental illness can be exponentially more difficult if you also have drug or alcohol addiction.
Substance Abuse and Mental Health Disorders: What is the Link?
Currently in the United States, there are nearly 8 million people living with both mental health conditions and substance use disorders. To break this down further, about half of individuals with severe psychological conditions, such as major depression, PTSD, schizophrenia, or bipolar disorder, also have a drug or alcohol condition. In those treated for substance abuse, 53% of those with a drug addiction meet criteria for a mental illness diagnosis. Likewise, 37% of alcoholics also have a substance abuse disorder. About 29% of those with a mental illness also have an alcohol or drug addiction.
These numbers are staggering. Clearly the risk of developing a substance abuse disorder while living with a mental illness – and vice versa – is significant and worthy of attention. With the high rate of co-occurring disorders, it is important that those living with either mental illness or a substance use disorder be aware of the risk of dual diagnoses.
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Which Happens First?
The question of which comes first – the mental illness or the substance abuse disorder – is a chicken or egg sort of situation. There are several scenarios where the development of one condition can impact the other. However, even though there is a strong link between mental illness and substance abuse, one condition does not directly cause the other, nor does it mean that someone with one disorder will automatically develop the other.
Alcohol or Drugs Use as Self-Medicating for Mental Health Symptoms
Self-medication with alcohol or drugs is, unfortunately, a common scenario. When a mental illness is undiagnosed, untreated, or under-treated, individuals may turn to alcohol or drugs to cope with symptoms of anxiety, depression, panic, or other symptoms of mental illness.
Additionally, some individuals with significant mental illness might not have healthy coping mechanisms to deal with common life stressors or major events. Some mental illnesses can impair judgment or make it difficult to draw upon healthy coping strategies. Thus, even if a person is treated for their mental illness, a death in the family, a job loss, or a significant financial stressor could cause the individual to turn to drugs or alcohol as a way to cope with the situation.
Alcohol or Drugs Increasing Risk for Mental Illness
For some people, mental illness can be triggered by drug and alcohol use. This is often due to genetics, but can also occur as a result of stressful situations. For people who are at risk of developing a mental illness, whether due to genetics, situation, or environment, sometimes alcohol or drug use can be the catalyst that triggers the onset of the psychological condition.
Research has also found that some drugs can actually lead to changes in the brain that lead to the development of mental illness. For example, recently, scientists have found that some adolescents that use marijuana later develop psychosis and schizophrenia. While some of these teens were already at a genetic risk for developing the psychological conditions, research also found that the risk of developing psychosis doubles in teens that smoke pot, even among those who do not have a genetic risk. This indicates that smoking pot can cause physical changes in the brain, at least during the adolescent years when the brain is still developing.
Another example of this is with long-term prescription opioid use. It has recently been discovered that extended use of prescription or illicit opioids can trigger symptoms of depression. In one study, it was found that over 10% of patients that used prescription opioids for at least a month developed symptoms of depression, while nearly half of those using heroin develop depression. Tragically, over 35% of those with heroin addiction die by suicide.
Treatment for Mental Illness Leads to Addiction
Finally, dual diagnoses can occur following the treatment for mental illness. Many psychotropic medications used to treat mental illnesses are actually significantly addictive. For example, benzodiazepines, which are used to treat anxiety disorders, are actually relatively easy to misuse and can be highly addictive.
Stimulant medications, such as Adderall and Ritalin, are considered to be Schedule II drugs, meaning that they have a high potential for addiction and abuse. This is the same category as cocaine, Vicodin, OxyContin, and fentanyl. Both Adderall and Ritalin are prescribed as a treatment for ADHD.
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Dual Diagnoses: Symptoms of Co-Occurring Substance Abuse & Mental Health Disorders
With the infinite combinations of substance abuse and mental health disorders that lead to a dual diagnosis, ensuring proper diagnosis can be complex. Sometimes, when both conditions are present at the same time, the symptoms of one condition can mask or alter the symptoms of the other, making it difficult to catch both conditions. Also, one individual with a dual diagnosis of PTSD and alcoholism will have a completely different set of symptoms than someone with schizophrenia and LSD abuse.
However, there are some signs of co-occurring disorders that might alert you or your medical professionals to the possibility:
- Having a history of trauma or abuse
- Having a previous mental health diagnosis that was resolved and is currently seeking treatment for substance abuse
- Using drugs or alcohol as a way to control pain, deal with unpleasant emotions, or cope with stressful situations
- History of unsuccessful treatments for either mental illness or substance abuse
- Anxiety, depression, insomnia, irritability, or panic attacks even when sober
- Family history of mental illness or substance abuse
- Noticing a connection between when you drink or use drugs and your mental health, for example, do you drink when you are anxious or do you become more depressed after you use opioids?
- Difficulty with quitting drinking, smoking, or using drugs because of overwhelming anxiety or depression
- Erratic behavior, even when not drinking or using drugs
- Isolating yourself from family, friends, or co-workers
- Inability to maintain consistent employment even when not using drugs or alcohol
- Legal problems related to behavior
- Using drugs or alcohol under dangerous conditions, such as while driving
- Feeling like you are unable to function without drinking or being high
Symptoms of Alcohol or Drug Abuse
If you already have a mental health diagnosis and you use drugs or alcohol, you might be wondering if your drug or alcohol use is considered to be abuse or addiction.
The following are symptoms that can indicate a substance abuse problem:
- Blacking out while drinking or using drugs
- Experiencing legal or employment problems due to alcohol or drug use
- Hiding drugs or alcohol at work or at home
- Doing or saying things you later regret while drunk or high
- Lying about how much you drink or use drugs
- Using prescription medication that was not prescribed to you
- Using prescription medication more frequently or at a higher dose than what was prescribed to you
- “Losing” prescriptions so that you can get additional prescriptions from your doctor
- “Doctor shopping” as a way to get more medication
- Trying to quit or cut back on alcohol or drug use but being unable to
- Feeling like you drink or use drugs too often
- Feeling bad or ashamed about your substance use
- Financial difficulties because too much money is spent on drugs or alcohol
- Spending time thinking about where your next fix or drink is coming from
- Needing increasing amounts of the drug or alcohol to feel the same effect
- Experiencing withdrawal symptoms when you stop using the drug or alcohol
- Drinking or using additional drugs to cope with withdrawal symptoms
- Engaging in risky behaviors or activities while high or drunk
- Continuing to drink or use drugs even when you know it is causing you problems in life or injuring your body
- Stealing medications or alcohol
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Common Co-Occurring Mental Health Disorders
While it is possible to have any mental health condition while also having a substance use disorder, the following types of mental illness are more commonly linked to an increased likelihood of substance abuse.
Anxiety
When anxiety occasionally occurs, it is considered to be a normal part of life. Anxiety can help us avoid dangerous or harmful situations by sending signals to our brain that a situation is risky. Occasional anxiety can also help us to stop and think through important decisions rather than acting on impulse.
However, sometimes, anxiety occurs without respect to the situation. For example, it can happen daily even when there is no situation that warrants anxiety, or a person can be anxious in harmless situations, such as having a phobia of flying. When anxiety interferes with a person’s everyday life, it becomes a disorder.
The following are symptoms of anxiety disorders:
- Worsening of anxiety over time
- Feeling restless or on edge
- Difficulty concentrating
- Being irrationally afraid of everyday situations, such as flying, being on an elevator, or spiders
- Avoiding situations or activities that cause you to feel anxious even when they are not dangerous or risky situations
- Insomnia or difficulties sleeping
- Difficulty with controlling feelings of worry
- Feelings of impending doom
- Heart palpitations, pounding heartbeats, or increased heart rate
- Sweating in situations that make you nervous
- Feeling like you are smothering, choking, or short of breath
- Shaking or trembling
Depression
Like anxiety, depression also has situations where it is normal and appropriate. For example, situational depression that occurs after the death of a loved one, following a job loss, or during a break-up or divorce is a normal and expected part of grieving. Situational depression often gets better over time. When feelings of depression continue for weeks or months at a time and they significantly impact your daily life, clinical depression might be a possibility. Symptoms of major depressive disorder (clinical depression) include:
- Feeling hopeless or helpless
- Difficulty concentrating
- Feeling worthless or guilty
- Loss of energy
- Sleeping too little or too much
- Decreased appetite or overeating
- Loss of interest in things you once enjoyed
- Feeling empty
- Thoughts of death or suicide
- Attempts at suicide
- Frequent and unexplained headaches, stomach aches, or other physical symptoms
- Decreased sex drive
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is often thought of as a condition that veterans experience after experiencing combat trauma during service. While this is true, nearly 8 million Americans have PTSD, many of whom are not veterans. Anyone that experiences a traumatic experience, such as the violent death of a loved one, rape, assault, natural disaster, a mass shooting, major car accident, house fire, or other life-threatening situations.
PTSD is an anxiety disorder that can occur in the weeks, months, or years following a traumatic event.
Symptoms of major depressive disorder (clinical depression) include:
Some symptoms of PTSD are:
- Repeated intrusive thoughts, memories, vivid dreams, or flashbacks of the traumatic event
- Ongoing fear, panic, or anxiety
- Being easily irritated or having angry outbursts
- Being easily startled
- Difficulties sleeping
- Avoiding places, people, situations, or objects that remind you of the traumatic event
- Increased anxiety or depression around the anniversary of the traumatic event
- Feeling detached from family and friends
- Distorted beliefs about self or others
- Avoiding discussing the traumatic event or your own feelings about the event
- Any of the symptoms of anxiety or depression that are ongoing following a traumatic event
Schizophrenia
Schizophrenia is a serious mental illness that is both chronic and complex. It is relatively rare, only affecting 1% of the population, but for those it affects, it can be life-altering. Most people with schizophrenia develop symptoms between the ages of 13 and 40, with males typically developing in their late teens and females developing symptoms in their late 20s.
Symptoms of schizophrenia include:
- Hallucinations – seeing, hearing, or feeling things that are not real
- Delusions – false beliefs that don’t change even when presented with facts
- Flat affect
- Speaking in a way that seems dull and disconnected
- Little interest in life and lack of motivation
- Unable to sustain relationships
- Difficulties with organizing thoughts or tasks
- Unaware that you have the illness
- Confused thinking
- Difficulties concentrating
- WIthdrawal from family and friends
- Drop in school or work performance
- Suicidal thoughts or attempts
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Bipolar Disorder
Bipolar disorder is a complex disorder that affects energy, mood, and ability to function. There are three classifications of bipolar disorder: bipolar I, bipolar II, and cyclothymic disorder.
Bipolar I is characterized by dramatic mood swings, with both manic episodes and depressive episodes. During manic periods, you might feel high, revved up, invincible, and “on top of the world”. You might engage in risky behaviors, have racing thoughts, feel that you don’t need to sleep, and have increased self-esteem, even to the point of grandiosity. During depressive episodes, you might feel sad and hopeless. In between, you might feel normal. Bipolar I can be diagnosed after just a manic episode, although the depressive episode can also be experienced.
People with bipolar II experience both mania and depression, but the episodes of mania are not as intense as with bipolar I. This less intense form of mania is known as hypomania. Both a hypomania and depressive episode need to be experienced before the diagnosis can be made.
Cyclothymic disorder involves a rapid cycling of depression, hypomania, and mania within a 12-month period. The symptoms might be less severe or intense than with bipolar I and II, but the mood swings will last at least half of the year, with no more than two months break.
Dual Diagnosis Treatment Options
If you have both a mental illness and a substance use disorder, you will need a treatment program that addresses both conditions. Often, mental health treatment includes options like group counseling, individual therapy, medication to manage symptoms, and lifestyle changes. Substance abuse treatment usually involves detoxification, behavioral therapy, support groups, and, in some cases, medication to manage withdrawal symptoms.
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Finding the Right Rehab and Treatment Program for You
When looking for a rehab and treatment program, it is important to find one that specializes in dual diagnoses. These facilities can provide treatment for both mental health disorders and substance use disorders. If only one disorder is addressed, the chance for a relapse of both remains high.
The right program will also individualize your treatment plan to your needs, allowing you to be actively involved in setting goals and giving input on what forms of treatment (holistic, 12-step, faith-based, etc.) will be most effective. A treatment facility with a variety of treatment options and modalities to choose from can assure that there is one that is right for you.
Finally, the right program will take into account lifestyle factors that impact your ability to heal. Specialized programs for professionals and executives and programs that address homelessness, unsafe living situations, or the need for job or educational resources can help you transition out of rehab and back to your everyday life.
Support Groups and Group Therapy Options
Support groups and group therapy are popular options for both addictions and mental health treatment. Some treatment facilities will also have groups for those with co-occurring disorders. Having peers that understand what you’re going through can be instrumental in your treatment and recovery process, especially since many mental illnesses or substance abuse disorders can be isolating.
These groups can be safe places to get support and discuss the challenges you are facing. Others in the group likely have gone through something similar and can help give you ideas of how they managed or they might simply be able to offer a listening ear so that you aren’t facing difficult situations alone.
Taking the First Step: How to Find Help
If you or someone you love is experiencing both mental illness and a substance use disorder, it is important to seek help. It can be difficult to take the first step and reach out, but doing so is the best way to get help with managing symptoms of mental illness and to begin the process of detoxing from alcohol or drug use.
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Denial in Substance Abuse & Mental Health Disorders
Unfortunately, in the United States, there is still a lot of stigma surrounding both substance abuse and mental illness. This stigma and fear of being mocked, fired from your employment, seen as being weak, or treated badly can keep you from seeking help. It might even cause you to deny that the problem even exists. In addition, the symptoms of mental illness might be frightening or uncomfortable, leading you to try to ignore the problem with hopes that it resolves on its own.
However, neither mental illness nor addiction to drugs or alcohol are likely to resolve without treatment. It is important to admit that you need help and to begin the process to find it. By taking that first step and calling a treatment facility that specializes in dual diagnosis, you can start your journey towards a healthy life.
You Are Not Alone: Important Tips to Remember
Foremost, it is important to remember that both mental illness and substance abuse are diseases and they can happen to anyone. You are not weak or a bad person – these diseases do not discriminate. They happen to rich or poor, people of every race and culture, those that are religious and those that aren’t. Mental illness and substance abuse aren’t punishment for bad things you might have done and you aren’t weak for seeking treatment. Nobody would look at someone with cancer and call them weak or bad for seeking treatment. Mental illness and addiction are both diseases, just like cancer.
It is also important to remember that you are not alone. While you might feel like nobody understands you or wants to be around you, there are people out there who love you and want you to heal and get well. There are also professionals ready to help you overcome your co-occurring disorders. You do not have to battle addiction and mental illness alone.
It is also important to understand that there is always hope. Both mental illness and substance abuse are treatable, even if the mental illness does not have a cure. You can live a full, healthy, and satisfying life with appropriate treatment and symptom management.
Next, remember to reach out for support. A strong support system, including your family, friends, medical professionals, and peer support groups can all help you get through difficult cravings, uncomfortable or distressing symptoms, or simply times where you feel down about your conditions. Your mental health and addictions treatment professionals are also part of your support system.
Finally, be gentle with yourself. Relapses in both your mental health condition and your substance abuse disorder can be a normal part of the recovery process. Don’t beat yourself up when these setbacks happen. With a strong support system and using the tools you learn during treatment, you can recover from relapses and slip-ups and continue moving forward on the path to a healthy and satisfying life.
If you or someone you love is currently experiencing drug or alcohol addiction with a co-occurring mental illness, reach out today to begin dual diagnosis treatment and start your journey to mental and physical health, free from alcohol or drugs.