How Does Someone Develop Co-Occurring Disorders?

By John Kahal, CEO of Capo by the Sea

Imagine being trapped in the vicious cycle of both a mental health disorder and a substance use disorder. On a daily basis, one condition continually aggravates and fuels the other, regardless of which one happened to emerge first. The co-occurring disorders, often referred to as a dual diagnosis or comorbidity, can lead to major impairment in functioning, impacting all aspects of daily life.

Unfortunately, co-occurring disorders are not rare and are, in fact, increasing in prevalence. The latest statistics provided by the National Alliance on Mental Illness state that approximately 9.2 million people struggle with addiction or chemical dependence and coexisting mental health conditions. The range of symptoms is diverse among those with a dual diagnosis, as the different mental health diagnoses, substance use history, and type of substance or substances involved dictate varying presentations of illness. Because of this, the treatment protocol will vary accordingly.

A dual diagnosis necessitates a specific treatment continuum for reaching a successful outcome. This involves medical detox, residential treatment at a dual diagnosis-specific treatment center, supportive housing, and ongoing aftercare programming. Both the psychiatric condition and the substance use disorder must be treated in tandem for optimum recovery outcomes.

How Does Someone Develop Co-Occurring Disorders?

A dual diagnosis begins with one condition, either the mental health disorder or substance abuse. The initial disorder is considered the primary condition. Someone who is battling depression, bipolar disorder, or an anxiety disorder may begin to use drugs or alcohol as a means of numbing the distressing mental health issue. Some may find themselves building up a tolerance to the substance, leading to ever increasing consumption. Over time, this may develop into chemical dependence or addiction, thus the dual diagnosis with the mental health disorder being primary.

On the other hand, it could be that someone who is struggling with a substance addiction may develop depression or anxiety as a result of the substance’s effects on the brain. Or, the negative consequences of the addiction, such as loss of a job, a failed marriage or relationship, financial hardship, custody battles, or legal problems, could cause one to become anxious or depressed as a result. In this case, the substance use disorder would be the primary diagnosis.

It is still unknown why some individuals acquire comorbidity while others do not, although it is believed that genetics, brain chemistry, and inadequate stress regulation are potential factors.

What are the Signs of a Dual Diagnosis?

Someone who has a psychiatric issue and co-occurring addiction will exhibit the signs and symptoms of each. These might include:

Unable to limit use of the substance or to stop using the substance
Obsessing about acquiring the substance, using, recovering from it, and then repeating the pattern the next day
Increased tolerance to the substance, leading to increased consumption
Lying about substance use, hiding the substance, stealing money for drugs or alcohol
Obtaining the substance illicitly, doctor shopping, stealing drugs from friends or relatives
Experiencing withdrawal symptoms when the substance is not available
Neglect of responsibilities or obligations
Work or academic performance suffers
Erratic mood swings
Changes in eating habits
Changes in sleep habits
Sleep disturbances
Sexual dysfunction
Excessive or irrational worry
Persistent sadness
Angry outbursts, irritability, agitation
Loss of interest in usual activities
Disregarding personal hygiene
Isolating behaviors

Treatment for Co-Occurring Disorders

Prior to beginning a treatment program for a dual diagnosis, the individual will undergo a thorough psychological evaluation and overall assessment. The information obtained through an interview with clinical staff, a physical exam, a review of medical and psychiatric history, and various diagnostic tools provides the data that allows the exact diagnosis to be arrived at. From that point, a customized treatment plan will be designed to guide the recovery process and to set recovery benchmarks and goals. The treatment plan that follows with include:

Medical detox. When approaching the recovery process, the first step will involve detox and withdrawal within a supervised setting. It is too difficult for the individual to attempt to undergo detox without support. As withdrawal symptoms increase in intensity, most individuals would simply give up on detox and return to the substance rather than suffer. For this reason, and to monitor the severity of the withdrawal symptoms, it is important to obtain a medically monitored detox. In the majority of instances, aside from detoxing from benzodiazepines, detox and withdrawal is completed in one week. The type and severity of withdrawal symptoms will be determined by the specific substance involved, how long the individual has had the substance use disorder, the age and general health status of the individual.

Residential dual diagnosis treatment. A dual diagnosis treatment program will entail the expertise of both a psychiatric staff and addiction treatment specialists. There are certain challenges involved in treating a dual diagnosis, as the mental health issue can become unpredictable once the person has stopped using the substance of abuse. This can cause disruption and distress within the treatment setting, which is why it is important to have a highly trained staff.

Treatment elements will include a collection of therapeutic interventions designed to help the individual learn how to manage the mental health condition without leaning on a substance. This involves learning new thought patterns and coping skills, which become the foundation upon which the recovery will be built. These treatment elements include:

Psychotherapy. There are several evidence-based therapies that are effective in treating someone with a dual diagnosis. These include:

- Cognitive behavioral therapy (CBT)
- Dialectical behavior therapy (DBT)
- Contingency management (CM)
- Assertive community treatment (ACT)

Psychotherapy is the centerpiece of dual diagnosis treatment, as it guides the individual in learning new positive responses to triggering stimuli. Therapy is provided in both individual and group settings. Family groups and couples therapy are also included in dual diagnosis programming.

Medication management. Medication is prescribed based on the specific dual diagnosis, or the combination of disorders present. Common medications for treating someone with a dual diagnosis are antidepressants, anti-anxiety medications (sedatives), antipsychotics, and mood stabilizers. Medication may also be indicated for assisting the addiction recovery process. Drugs such as naltrexone or buprenorphine are sometimes prescribed for aiding opioid addiction and alcoholism recovery. These can help reduce the desire or cravings for the substance and stabilize recovery.

Education. Individuals in treatment benefit from acquiring a basic understanding of the mechanism of addiction, how it develops in the brain, and subsequently alters brain pathways. The classes teach recovery skills, such as coping techniques, communication skills, and emotion regulation techniques. Each individual will design a custom relapse prevention plan that takes into consideration their own unique set of triggers, then create an action plan to access in recovery.

Recreation and nutrition. While mental health treatment is a core aspect of overcoming a dual diagnosis, another important element involves restoring one’s physical health. In treatment individuals are encouraged to shift to a healthy diet while limiting processed foods and sugars. In addition, getting regular exercise through recreational activities, such as golf, hiking, sports, surfing, or horseback riding can increase the production of endorphins, as well as dopamine and serotonin, which have positive effects on mood and sleep quality.

Holistic. Addiction treatment programming is increasingly including holistic activities into their list of treatment elements. Holistic therapies, such as massage, sauna, acupuncture, mindfulness coaching, and yoga have been found to complement the traditional clinical therapies by enhancing relaxation and reducing stress.

Aftercare is as critical to recovery as active treatment. This is because it is through aftercare support that the individual is able to solidify a new sober lifestyle. Generally, aftercare includes three basic elements:

Supportive housing. While not a requirement for recovery success, residing for a certain period of time in a safe, substance-free environment can be protective against the threat of relapse. Many who leave residential rehab and immediately return to their home community are ill-prepared for the immediate challenges to their sobriety they may face. This is especially true when the home environment is not supportive of recovery efforts. Sober housing offers a more controlled environment for a more gradual transition back home.

Outpatient services. After receiving ongoing therapy for an extended period, it may be risky to go it alone immediately after rehab is completed. By continuing to engage in outpatient therapy and support groups individuals in early recovery have access to much needed reinforcement when they face challenges.

Recovery community. Becoming actively involved in a local recovery community can offer social support and a source of accountability to others. This can provide the mutual support so important in recovery, as well as opportunities to connect with others committed to sobriety. “Double Trouble” meetings are an offshoot of A.A.’s 12-step program that were created for individuals with a dual diagnosis. There are also A.A., N.A., SMART Recovery, S.O.S, and others to choose from.

While a dual diagnosis involves unique challenges in both treatment and recovery, the co-occurring disorders can be managed, and a robust quality of life can most definitely be achieved.

If you or someone you know experiences mental health issues, it is important to seek help from a qualified professional. Our Resource Specialist can help you find expert mental health resources to recover in your community. Contact us now for more information on this free service to our users.

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Author Bio: John T. Kahal is the founder and CEO of Capo By the Sea, a luxury addiction and dual diagnosis treatment program located in South Orange County, California. After his own successful experience with the recovery process and journey, Kahal decided to create a unique program that was individualized for each client’s specific treatment needs. Kahal’s passion to share his own positive experience with others, while being a living example of the freedom found in recovery, is what motivates him to guide clients toward their own stable, long-term recovery.

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