What is Dual Diagnosis?

A submission by Students Against Addiction
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There are few subjects in American pop culture talked about so freely as recreational drug and alcohol use, however few subjects are met with more taboo than drug and alcohol treatment. In 2012 survey, 23.9 million Americans 12 and older used illicit drugs or abused prescription medications in the previous month; sadly only 2.5 million of those Americans sought treatment from a specialty facility. A growing issue is coming to light for those suffering with addiction – dual diagnosis. These individuals have both a substance addiction, such as drugs or alcohol, as well as a mental illness, such as depression or anxiety. Over one third of all alcohol abusers and half of those addicted to drugs suffer from some kind of mental illness.

Dual diagnosis, also called co-occurring disorder or COD, is not a new problem but it is finally getting the attention – and for those suffer, the treatment – it needs. Early intervention could prove to be crucial as half of all lifetime cases of mental and substance disorders begin by the age of 14 and 75% by the age of 24. In some cases drug use brings on the first episode of psychosis, called substance induced psychosis. Recovery for these individuals can be very challenging, as is diagnosis.

Self Medicating

One of the biggest stumbling blocks for diagnosis and recovery is self medicating. Often when someone suffers from a mental illness they turn to alcohol or drugs to help cope with the problem. Unfortunately, in many cases these same substances make mental illness infinitely worse and often limit the help a patient might try to get. If the treating doctor is not informed of the problem it may lead to one issue being treated while the other goes on unchecked. This can lead to a deadly mix of psychotropic drugs and alcohol or other illicit drugs, as a psychiatrist tries to assist with the mental illness. Inversely, if only the addiction is treated relapse is very likely as the underlying cause of the need for drugs has not been resolved.

A major issue of self medicating is that the underlying mental illness often goes untreated. Someone who suffers from depression may self medicate with alcohol or psychostimulants, such as cocaine or amphetamines. Not only do drugs and alcohol explain some of the symptoms of mental illness, the side effect of abuse for those substances is often depression, leading into a seemingly never-ending cycle. There is a theory that the drug or substance of choice for self medicating is more than mere coincidence, the theory states that the substance used can help to identify the illness and often will be a treatment in itself in small doses. A patient suffering from an anxiety disorder may prefer the effect of marijuana even over prescribed medication as diagnosing and treating a mental illness is a long journey and finding the right medication with the right dosage is a difficult process. In the mean time marijuana can give the user an illusion of a calmer state of mind while avoiding feelings of numbness, which is often the complaint of those on anti-anxiety medications.

Common Disorder Signs

As unhealthy as self medicating is, it is almost more important not to self diagnose. Only a trained mental health professional should diagnose a patient and then help that patient to find the right treatment path for them. While there are a multitude of illnesses that could couple with a substance abuse problem, there are some that are more common than others. These illnesses often have signs and symptoms that are looked over as being part of a reaction to drugs or alcohol instead of as the warning signs they are truly meant to be. When an individual exhibits several of the following symptoms their problem could be more severe, clinical, and may need help beyond that of substance abuse rehabilitation:

Feeling sad and crying often
Feeling hopeless or empty
Decline in energy or a state of constant exhaustion
A sudden change in sleep pattern, either sleeping too often or sleeping rarely
Fluctuation in eating habits, from not eating much at all to overeating
Irritability or irrational anger
Worry, anxiety
Inability to concentrate or make decisions
Not wanting to socialize or engage in formerly enjoyable activities
Frequent thoughts of suicide or obsession with death

Another common condition for self medicating is bipolar disorder. This condition has periods of high activity or mood elevation, known as manic episodes, followed by depressive episodes. People suffering from this illness often self medicate depending on which part of the cycle they are in and because these periods or episodes change it can be hard for loved ones to see the problem is more severe than the effect of the drug during manic episodes or simple effects of withdrawal from a substance during depressive episodes. Signs of bipolar can be some or all of the following for a manic episode:

Long period of feeling high or extreme happiness
Severe irritability
Racing thoughts or talking so quickly words stumble over each other
Taking on many new projects
Not sleeping or sleeping very little
Being distracted easily
An unrealistic belief in ones’ abilities
Behaving impulsively, engaging in high risk activities or sexual promiscuity

Anxiety disorders can be one of the most difficult to recognize as a co-occurring disorder. It has become commonplace to take a drink if you are feeling anxious at a party, and this blase attitude can lead to abuse and finally addiction. Unlike depression or bipolar, those suffering from anxiety are often encouraged to self medicate and it can be years before the realization that there is an underlying illness, usually only occurring after the person has become sober.. Not only are symptoms often ignored or concealed, but diagnosis itself can be difficult as there is a large variance in types of anxiety and severity. The following symptoms are a generalized list of symptoms for anxiety disorders:

Feeling restless or “jumpy”
Persistent worry or excessive tension
Racing heart or shortness of breath
Irritability
Difficulty concentrating
Difficulty sleeping
Headaches or muscle tension
Dizziness, trembling or nausea

Treatment

No matter what mental illness is co-occurring, treatment is vital for recovery. Of those with co-occurring disorder or those dually diagnosed only 7.4% receive treatment for both conditions, while 55.8% receive no treatment at all. Choosing an integrated treatment facility can help with the process of detoxification from the addictive substance as well as the support for treatment of the mental illness. Detoxification can be a painful and dangerous process if not done correctly; not only do treatment facilities provide medications to assist with pain and other withdrawal symptoms, they also provide privacy during this emotional and difficult time. When the body is going through such an intensive process as detox it can be hard for loved ones to watch and they can be especially vulnerable to pleas for the drug or hurt by unintended insults while the patient is not in their right frame of mind.

It can also be extremely important to go to a facility for medical reasons. Detox and withdrawal are strenuous on the body and come with many risks. While the initial phase of detoxing drugs or alcohol from the body may be two to three days, the longer process of the brain regulating function and learning new ways to think can take months, during this crucial period relapse is common. The majority of severe medical dangers are in the initial phase, and depending on the level of previous dependence or addiction may include:

Heart failure
Vomiting
Trembling
Seizures
Hallucinations

Heroin in particular has severe detoxing effects and is never safe to detox alone. As heroin is an opiate the body becomes easily and quickly accustomed to; withdrawal is often painful, and effects of withdrawal can start as soon as twelve hours since the drug was last used with the worst symptoms persisting four days. Symptoms can include:

Body pain
Vomiting
Diarrhea
Abdominal pain
Sweating
Chills
Weakness

A deceptively difficult drug detox is from methamphetamines, as there a few physical symptoms. The hazard with these drugs are the psychological withdrawal symptoms, which can be dangerous and painful. Often the psychological effects may not seem detox related at all but prove to be a threat to not only the person detoxing but anyone else nearby not trained to help. Methamphetamine withdrawal can include:

Aggression
Anxiety
Paranoia
Severe depression
Irritability
Suicidal thoughts
Fatigue that can result in sleeping for days
Lethargy

After Detox

Once someone suffering from co-occurring disorder is free of the substance and has a sober mind to dedicate to recovery, the true treatment process can begin. It has been shown in countless studies that the best chance for recovery is a program that targets both the substance addiction and the mental illness, known as an integrated program. If the patient enters a facility ill prepared to handle both problems then the chance of relapse becomes almost a certainty. As with any kind of treatment, it is incredibly important to choose a program or facility that will best suit the patient and can form a recovery program based on individual needs; no one person has the same addiction or illness, and each person’s path to recovery is unique.

Dual Recovery Anonymous

One growing trend in attempting recovery is the 12 step program which has now been adapted to fit the needs of those with dual diagnosis., also called Dual Addiction Anonymous. This program started in the late 1980s by Tim H., a man also recovering from co-occurring disorder. He noticed a lack of support groups for those with this diagnosis and started a small group that went through a modified version of the well known 12 step program recognized by Alcoholics Anonymous. DRA founds groups based on the steps and stories of others also recovering – this program is a self-motivated program and requires intense willpower and commitment. The group holds meetings frequently – often a group will meet weekly, but can be more often if needed and some find it helpful to attend up to and even more than once a day. DRA partnered with AA, Alcoholics Anonymous, has counseling available as well as several specialized groups for those of different faiths, women only, men only, teens, gay and lesbian or other specific needs.

The 12 step model has been used across the country and it has the same general objectives for its’ members. The first step and objective is acceptance. This can be the most difficult for some and it the process of recognizing that the member has both a person with substance use disorderion and a disorder, the member must also accept that they are powerless over these two things. As the 12 step program is religious in nature the second objective is help and find an a Higher Power to assist the member with recovery. The program does note that while this source of help is normally called a Higher Power, the member can choose any name they feel comfortable with using.

As this program is designed with self help in mind, identifying assets and liabilities also becomes important. An asset is any attitude, action or experience that can assist the member with dual diagnosis recovery, such as strong work ethic or optimistic outlook. A liability would then be any attitude, action or experience that has the potential to be a risk for recovery, such as visiting friends that still use drugs or self indulgent attitude. Following this identification is change, working with the member’s belief in their chosen Higher Power to strengthen the assets and eliminate the liabilities to give the member the best chance at a lasting recovery.

Mending relationships can be a difficult journey for those members recovering from co-occurring disorder. It is likely that in the thrall of addiction they have done acts that have harmed others as well as themselves. This objective comprises several steps and is vital for recovery. Seeking out those they have harmed and making amends helps members move forward to a healthier place and creates a fresh start. The 12 step program acknowledges that not all of those harmed will be easy to mend and that the member may need to work faithfully at mending that relationship.

To prevent a relapse, the member must continue to rely on the Higher Power for help in strengthening assets and eliminating liabilities. This process is a constant one that will continue even after the program is complete. Finally, the member must help others much in the way they received help from members. This can be with sharing their success to give new members hope for recovery or in counseling others.

Outpatient Care

In the same vein as support groups, outpatient care is designed for the patient to attend meetings or sessions while living at home. Sometimes out patient care is performed at a sober house or halfway house, this provides an extra level of support and is often the midline between inpatient care and outpatient care. These sober homes are normally affordable and have mandatory meetings which provide structure. Traditional outpatient care is sometimes chosen because the patient has work or family commitments which prevent full time care at a facility but do assist with a strong support group. Also, teens with involved and supportive parents normally end up in an outpatient situation, attending during the day while benefitting from their family support at other times.

The primary focus of outpatient treatment is counseling. This can be individual therapy which involves meeting with a mental health professional and setting up a treatment plan. The patient becomes responsible to meet goals and be honest with that professional. The patient can also go to group or family counseling, this may be ideal for young adults or teens that may have issues with family that could influence their addiction and disorder recovery.

Other types of counseling can be cognitive behavioral therapy, or CBT; this type of counseling helps to reveal the connection between thoughts, feelings, and behaviors. This therapy seeks to change destructive thought patterns that lead to poor behaviors and also the beliefs that fuel give these thoughts voice. CBT impresses the importance of modifying behaviors over just finding out the reason for the behavior. It also encourages a strong working relationship between doctor and patient to work together to better the patient. Patients in this treatment are encourage to keep a journal of “automatic thoughts”, ideas that come to mind seemingly from nowhere. This helps patient and doctor to map out thought patterns and ultimately change destructive thoughts and promote positive behaviors.

Outpatients may enter counseling that focuses on motivational incentives. Under this treatment patients are rewarded for good behavior using positive reinforcement. Motivational interviewing is a treatment that uses the patient’s willingness to get help as a motivation to change drug seeking behaviors.

Inpatient Care

The most successful recovery program is often inpatient care, and these facilities often have an integrated treatment program that also is individualised to each patient. These programs will offer all of the above treatment options, along with a structured schedule to assist with recovery. Most patients find the structure comforting in a time of turmoil in their lives. Inpatient treatment also provides 24 hour supervision, and this can be vital as patients are learning to resist temptation and curb destructive tendencies.

Another important benefit of inpatient treatment is that patients are removed from the daily stresses of life and are able to focus fully on themselves. Intensive therapy and medication adjustments can be difficult and trying to balance work or family can make recovery seem impossible. The facility also helps to remove triggers, either physical or emotional, and in their place gives patients the tools needed to avoid relapse once the patient integrates back into society. Inpatient facilities can provide a safe place to heal from the trauma of addiction and a secure place to start treatment of mental illness.

Medications are normally prescribed to those with mental illness as well as those recovering from substance addictions. For those with a dual diagnosis, finding the right medication becomes a complex task. For this reason, doctors encourage an inpatient treatment where medication can be monitored and any medical issues can be addressed. Not only can the patient inform their doctor of side effects but the staff are also monitoring and are able to provide an objective opinion.

As it has been previously stated, detoxing from a substance addiction should be done in a facility that can monitor the patient for health and safety reasons. Choosing an inpatient facility provides convenience of doing all parts of recovery as well as keeping the same doctors. Information gathered during the detox phase can prove to be vital in the recovery process.

No matter which treatment option that a patient chooses the important choice is to get help. Co-occurring disorder can be difficult to diagnosis and even harder to treat. Finding the proper recovery path can greatly increase the chance of success and help to avoid relapse. Without seeking that treatment the chance of HIV infection, imprisonment and even death increase exponentially

Resources:

https://www.drugabuse.gov/publications/drugfacts/treatment-statistics

https://www.samhsa.gov/

drugfree.org

https://www.healthline.com/health/depression/forms-self-medication

https://draonline.org/