Co-Occurring Disorders

When a person is diagnosed with both a mental illness and a substance use disorder, he or she is said to have co-occurring disorders. Approximately eight million U.S. adults have co-occurring mental health and substance use disorders. Screening for both types of conditions is crucial, because each affects the other, and the most effective treatment plans address all of an individual’s mental, behavioral, and physical health needs. Treating only one condition can cause the other to worsen or lead to relapse in the condition being treated.

What Are Co-Occurring Disorders?


Mental and behavioral health professionals use the term co-occurring disorders to refer to a situation in which a patient has more than one mental illness or especially when they have both a mental illness and an addictive disorder. This situation is also often referred to as a dual diagnosis. It is important that anyone struggling with mental illness or substance abuse be screened for the other type of condition or for additional mental illnesses.

The best and most effective treatment for any patient struggling with either of these issues involves treating all existing conditions. Treating only substance use disorders and ignoring a mental illness puts a patient at serious risk for complications and a later relapse. Treating mental illness without addressing substance abuse often leads to recurrences of symptoms and makes the condition difficult to manage.

Symptoms and Diagnosis of Co-Occurring Disorders


Diagnosing patients who struggle with both substance abuse and mental illness can be complicated. There are many overlapping symptoms and symptoms that are changed or affected by one condition or the other. The signs that a patient may exhibit depend on the specific substance being used and the mental health condition. Some general signs of mental illness, substance misuse, or both, include:

  • Unusual changes in mood or a depressed or anxious mood
  • Difficulty thinking or concentrating
  • Changes in behaviors that seem unusual and can’t be explained by a current situation
  • Difficulty coping with ordinary responsibilities or normal stress levels
  • Withdrawal from friends and family
  • Decreases in performance at work or school
  • Changes in eating or sleeping habits without another explanation
  • Fatigue, tiredness, or lethargy and loss of interest in activities
  • Decrease in personal hygiene
  • Difficulties in relationships with others
  • Changes in sex drive or sexual function
  • Thoughts of suicide, self-harm
  • Substance use that is out of control, causes cravings or withdrawal, or that takes over a large portion of time and energy, displacing other activities

Diagnosis of co-occurring disorders must be done by a healthcare professional. These professionals use accepted standards to determine which types of mental illness a patient has and whether or not they have substance use disorders. They rely on medical evaluations, patient interviews, observations, and talking to family members to make diagnoses.

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Causes and Risk Factors


There are many possible causes of co-occurring disorders. It may not be possible to identify what triggers two or more conditions in one individual, but there are several reasons why it is likely to happen. For instance, mental illnesses and substance use disorders have similar risk factors:

  • A family history of mental illness or substance abuse
  • Going through a very stressful or traumatic experience
  • Having a chronic physical illness
  • Experiencing abuse, neglect, or other type of trauma as a child
  • Having a poor social support network, including poor family support

These risk factors make it more likely that a person will develop a mental illness, but also that a person will abuse or become dependent on drugs or alcohol. There are other risk factors specific to each type of condition, but these overlapping factors help to explain why so many people develop dual disorders.

It also may be possible that having a mental illness, especially one that has gone undiagnosed and untreated, triggers substance abuse. The individual who suffers with mental illness symptoms may turn to prescription or illicit drugs to self-medicate. It is an unhealthy but fairly common type of coping mechanism.

On the other hand, a person who misuses drugs and alcohol may be more likely to develop a mental illness. Mind-altering substances can impact the brain and mental health. They can trigger episodes of an underlying mental illness or contribute to the development of a mental illness in someone who is already predisposed to it by other risk factors, like family history.

Withdrawal and Detox


Someone struggling with co-occurring disorders will need to go through a period of detox before continuing with a comprehensive treatment program. Detox is the process of a drug leaving the body, and when someone has been using long enough to develop a tolerance and cravings, they are likely to experience uncomfortable withdrawal symptoms during detox. The exact symptoms vary by individual and the type of substance, but generally may include:

  • Pain
  • Loss of appetite
  • Insomnia or excessive sleepiness
  • Irritability, anxiety, anger
  • Disorientation and confusion
  • Depression and anxiety
  • Nausea, vomiting, abdominal cramps
  • Tremors
  • Sweating

In severe cases of addiction, withdrawal may cause serious and dangerous symptoms. Anyone who is struggling with substance abuse should go through detox under medical supervision, both to stay safe and to avoid relapsing.

Common Co-Occurring Disorders


Any combination of substance type and mental illness is possible, but there are some that are more common. For example, one study of hundreds of patients receiving outpatient care for substance use also screened the patients for mental illnesses. The results showed that depression and anxiety disorders were most common. The researchers also found that more than one-third of these patients had two or three underlying mental illnesses.

A study of patients in medically-assisted treatment for opioid drugs found that there were some common co-occurring mental illnesses: depression and anxiety disorders, bipolar disorder, schizophrenia, borderline personality disorder, narcissistic personality disorder, antisocial personality disorder, and attention deficit hyperactivity disorder.

With more severe mental illnesses, like schizophrenia and bipolar disorder, there are some more common types of substance use. For instance, with schizophrenia, rates of smoking and nicotine addiction are high. Schizophrenia also often co-occurs with abuse of marijuana and alcohol. Nearly half of people diagnosed with schizophrenia struggle with substance abuse of some type. Substance use is also very common with bipolar disorder, affecting as much as 60 percent of this group.

Treatment and Prognosis


Co-occurring disorder treatment is based on the idea that it is necessary to address all conditions a person is struggling with rather than treating one at a time. One of the principles of effective addiction treatment is that all needs of an individual should be addressed, including mental health. This is also known as integrated treatment, and it involves treating each co-occurring disorder as a primary, not secondary, condition.

Treatment begins with detox, but this is only the first step in what should be a long-term plan. The plan needs to include comprehensive care for both addiction and mental illness. For some patients this may include medication. Medications can be useful in managing symptoms of many mental illnesses, such as antidepressants for major depression or antipsychotics for schizophrenia. Medication-assisted treatment may also be used for substance abuse, especially with addiction to opioids.

Medication is not a comprehensive treatment plan and should be combined with a variety of therapies. There are many types of therapy that can be used to treat both addiction and mental illness, and this allows for each patient to get a tailored plan that works best for their needs. A residential treatment facility can provide a wide range of options, including behavioral therapies, trauma-focused therapies, family and relational therapy, and group therapy and support, although many patients also respond well to therapy in an outpatient setting.

Medications and therapy while in treatment are the foundation for patients with co-occurring disorders, but they also need to learn the tools for preventing drug or alcohol relapses once out of intensive treatment. An effective treatment program will include plans for relapse prevention, including healthy lifestyle habits, positive stress reduction strategies, trigger avoidance, ongoing social support, and good self-care.

Co-occurring disorders are not uncommon, but they cause a great deal of complexity for patients who are seeking treatment. It is crucial that anyone with any mental illness or substance use disorder is screened for other conditions, so a dual diagnosis can be made if appropriate. It is only when treatment is implemented for all conditions that a patient can really benefit and get the care needed to live a normal, functioning life.