What is a Dual Diagnosis?
While evaluating people for substance abuse issues, addiction specialists may detect psychological, emotional or behavioral symptoms that don’t fit the substance abuse profile. When this happens, they are likely to refer the client to a mental health expert, who is trained to diagnose mental health conditions if they are present.
Should the person ultimately be diagnosed with a mood, anxiety or personality disorder, in addition to their substance use disorder, this is referred to as a dual diagnosis. People who carry a dual diagnosis require specialized treatment that addresses each condition simultaneously, preferably in a residential treatment center with a well-established dual diagnosis program.
Making a Dual Diagnosis for Substance Use and Mental Health Disorders
Mental disorders create a clear break with the past, and people who develop them will know something is wrong, even if they don’t know exactly what it is.
Every mental health disorder produces different symptoms. But all disrupt daily functioning and have the potential to cause significant problems in every area of a person’s life.
Mental health professionals rely on the testimony of clients and their family members, plus previous medical records, to make a precise diagnosis for a mental disorder. Since many mental health conditions have similar (or even identical) symptoms, diagnosticians must take great care to ensure they identify the correct disorder (or disorders) so treatment can be properly targeted.
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The process can be complicated, but mental health experts are trained to make these distinctions.
Diagnosing a substance use disorder is somewhat more straightforward. The symptoms that addiction experts look for are distinctive to chemical dependency, and the standards don’t change depending on the substance being abused.
To receive a diagnosis for a drug use or alcohol use disorder, clients must report two or more of the following signs of addiction during the evaluation process[1]:
- A growth in tolerance for one or more substances (more drugs or alcohol must be taken achieve the same effects)
- Withdrawal symptoms have been experienced during attempts to stay drug- or alcohol-free
- Previous attempts at abstinence have all failed
- Episodes of excessive and unplanned consumption have become common
- Cravings for drugs or alcohol have been experienced often
- Significant time has been lost using drugs and alcohol, procuring them and/or recovering from their effects
- Use of substances has resulted in neglect of home, work, family or personal responsibilities
- Drugs or alcohol have been used in risky situations (for example, when driving)
- Use has continued despite a significantly negative impact on relationships
- Previous hobbies or other enjoyable activities have been discontinued in favor of substance use
- Drinking or drug use has continued despite its contribution to other mental and physical health problems
Successfully diagnosing someone with co-occurring substance use and mental health disorders is challenging. But studies reveal that more than 40 percent of people with substance use disorders have comorbid mental health conditions, so diagnosticians are aware of the risks and are always on the alert for signs of co-occurring conditions[2].
Risk Factors for a Dual Diagnosis
The relationship between substance abuse and poor mental health is at least partially explained by common risk factors. Causation is a more complicated topic, but people who share certain characteristics and life experiences are more likely to develop addiction, mental illness or both once they reach adulthood.
Some of the shared risk factors for a dual diagnosis include:
Heredity
Studies carried out on identical twins have established an elevated risk for substance use disorders based on genetic (inherited) factors, and the increased risk covers all categories of intoxicants[3]. Meanwhile, other studies have shown that having a close family member with a psychiatric disorder is the most significant predictor of mental illness later in life[4].
Consequently, many people with co-occurring disorders come from families that have a history of both substance abuse and mental health problems.
Childhood Abuse and Neglect
In various surveys, about two-thirds of people seeking treatment for substance use report incidents of childhood abuse and neglect[5]. Similarly, there is a well-established connection between childhood mistreatment and mental health disorders, of all types.
In a 2012 Harvard University study, people exposed to three or more types of childhood mistreatment (verbal, sexual or physical abuse, or severe neglect) were at extreme risk for at least two mental health disorders: major depression (53 percent had experienced it) and PTSD (40 percent were diagnosed)[6]. Significantly, these men and women exhibited changes in brain activity that are associated with an increased risk for both mental illness and substance use disorders.
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Social Isolation and Loneliness
People who struggle with substance use and mental health troubles frequently lack strong support networks and have few close relationships. In one research project involving older adults, only 25 percent of participants who experienced loneliness and isolation reported “very good” or “excellent” mental health[7]. The relationship between social isolation and depression is particularly strong—and having depression more than doubles a person’s risk for substance use disorders[8].
Social isolation also has an impact on addiction. In one study of people receiving treatment for substance abuse, 63 percent were single and 42 percent reported spending most of their time alone[9].
Consequences of Co-occurring Disorders
Long-term substance abuse can create emotional and behavioral health problems. But in most instances, substance use issues develop in response to pre-existing mental health conditions.
When people self-medicate with drugs or alcohol to cope with disturbing mental health symptoms, their chances of developing a substance use disorder are high. In any given year, about 18 percent of people with a mental health disorder will also struggle with chemical dependency, which is more than double the risk for the general public[10].
Undiagnosed or untreated comorbid conditions can have severe consequences, even beyond those encountered by those who have only one mental or behavioral health condition[11]. Those consequences may include:
- A more rapid than usual decline, as the symptoms of the substance use and mental health disorders reinforce each other
- Emotional instability and volatility
- Multiple physical health problems and illnesses
- Elevated risk for drug or alcohol overdose
- Inability to manage medications or comply with other medical requirements
- Greater risk for psychotic breakdown
- Increased incidence of self-harming practices or suicidal behavior
Getting a dual diagnosis can be frightening. But the effects of it can be even worse, and the sooner an accurate diagnosis is provided, the sooner treatment can begin.
The Importance of Dual Diagnosis Treatment
Dual diagnosis treatment programs give people with co-occurring disorders true hope for recovery. These inpatient treatment plans are comprehensive, intensive and carefully designed to treat all symptoms equally.
But the majority of people who qualify for dual diagnosis treatment don’t actually receive it.
In 2016, only 6.9 percent of American adults suffering from co-occurring mental health and substance use disorders enrolled in dual diagnosis treatment programs, even though 48 percent did seek help for their symptoms[12]. In these cases substance use issues in particular are frequently overlooked, which explains why nearly 80 percent of those who sought treatment received help for their mental health issues only[13].
These statistics are unfortunate, because inpatient dual diagnosis treatment programs have an excellent track record of success. Having co-occurring conditions does make the process of recovery more complex, but with a customized menu of integrated mental health and substance use therapies, medication, holistic healing practices and life skills classes, and other educational and self-development initiatives, long-term sobriety and improved mental health are achievable goals.
[1] Medina, Johnna MD. Symptoms of Substance Use Disorder.
https://psychcentral.com/disorders/addictions/substance-use-disorder-symptoms/
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[2] Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health.
https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#adults
[3]Ducci, Francesca MD and Goldman, David MD. The Genetic Basis of Addictive Disorders.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506170/
[4]Frances, Allen J. MD. What You Need to Know about the Genetics of Mental Disorders.
https://www.psychologytoday.com/us/blog/saving-normal/201604/what-you-need-know-about-the-genetics-mental-disorders
[5]Elwyn, Laura and Smith, Carolyn. Child Maltreatment and Adult Substance Abuse: The Role of Memory.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3852601/
[6]Svalavitz, Maia. How Child Abuse Primes the Brain for Future Mental Illness.
http://healthland.time.com/2012/02/15/how-child-abuse-primes-the-brain-for-future-mental-illness/
[7]Cornwell, Erin York and Waite, Linda J. Social Disconnectedness, Perceived Isolation and Health among Older Adults.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2756979/
[8]Anxiety and Depression Association of America. Substance Use Disorders.
https://adaa.org/understanding-anxiety/related-illnesses/substance-abuse
[9]Dingle, Genevieve A. et al. Social Identities as Pathways into and out of Addiction
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663247/
[10] Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health.
https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#adults
[11]Buckley, PF. Prevalence and Consequences of the Dual Diagnosis of Substance Abuse and Severe Mental Illness.
https://www.ncbi.nlm.nih.gov/pubmed/16961418
[12] Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health.
https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#adults
[13]Ibid.
