In a general sense, the term co-occurring disorders refers to any two disorders that are present in the person at the same time. However,
In the mental health field, the term has come to specifically refer to an individual who is diagnosed with some psychiatric/psychological disorder (e.g., depression, panic disorder, bipolar disorder, etc.) and also a substance use disorder.
The term substance use disorder (SUD) is the latest classification by the American Psychiatric Association (APA) that covers substance abuse and addictive behaviors.
The situation where an individual is diagnosed with a mental health disorder and a comorbid (co-occurring) substance use disorder was previously referred to as a dual diagnosis. Although all of these terms are often used interchangeably, the preferred term is now co-occurring disorders. Co-occurring disorders defined in this context are quite common.
There is a quite a bit of data regarding the prevalence of co-occurring mental health disorders among those with addiction problems. The situation is not uncommon. According to the National Institute of Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA):
- Nearly a third of all people diagnosed with some form of mental illness or psychological disorder also have a substance use disorder.
- When severe mental health disorders, such as post-traumatic stress disorder, schizophrenia, or bipolar disorder are considered, nearly half of these individuals also have a substance use disorder. This suggests that more severe forms of psychopathology are more vulnerable to the development of substance abuse issues.
- A large number of people with diagnosable co-occurring disorders are incarcerated.
- Co-occurring disorders are disproportionately represented among individuals from lower social economic statuses and from conditions of poverty.
- Veterans of the Armed Forces have higher rates of co-occurring disorders than non-veterans, most likely due to issues with post-traumatic stress disorder.
- Males are more likely to be diagnosed with co-occurring disorders that females.
People suffering with a co-occurring psychological disorder and substance use disorder present a specific challenge in treatment. This is because when these both conditions co-occur, the result is a number of complications that interact in every facet of the individual’s life. For instance:
- People with co-occurring disorders have more medical complications as a group than individuals with one disorder or no history of a psychological disorder. This includes avoidable health issues, such as diabetes, sexually transmitted diseases, and hepatitis.
- People with co-occurring disorders have significantly higher rates of divorce.
- People with co-occurring disorders are far more likely to have issues with unemployment or homelessness.
- People with co-occurring disorders are significantly more likely to have a history of violence.
- People with co-occurring disorders are more likely to relapse after treatment.
- People with co-occurring disorders have significantly higher rates of suicide.
Because there are many possible combinations of mental health disorders and substance use disorders that occur together, the symptom profile associated with an individual with a dual diagnosis can vary widely. The general symptoms associated with a substance use disorder include:
- The person withdraws from social situations, including from friends and family.
- The person feels like they need the substance to deal with stressful situations or just to be able to function normally.
- The person uses substances in inappropriate or dangerous conditions.
- The person appears to have no control over substance use.
- The person engages in risky behaviors when they use the substance.
- The person uses increasing amounts of the substance in order to attempt to get the same effect that they got from smaller amounts before.
- The person develops flulike symptoms if they do not use the substance of choice within a day or two.
According to the American Society of Addiction Medicine (ASAM), some of the most common co-occurring diagnoses are:
- Major depression and an alcohol use disorder
- Any type of anxiety disorder and an alcohol use disorder (Anxiety disorders include phobias, panic disorder, agoraphobia, and generalized anxiety disorder.)
- Certain personality disorders, such as borderline personality disorder or antisocial personality disorder, and either a cocaine use disorder or an alcohol use disorder
- Schizophrenia and tobacco use disorders or cannabis use disorders
Although a co-occurring disorder can include any psychological disorder, there are several other psychological disorders that appear to be particularly vulnerable to the development of substance use disorders. These include:
- Stress and trauma-related disorders, including post-traumatic stress disorder
- Attention deficit hyperactivity disorder (ADHD)
- Eating disorders, such as anorexia and bulimia
- Bipolar disorder
Any identified class of substances that can be abused can potentially be part of a co-occurring disorder or dual diagnosis. While some combinations appear to be more common than others (e.g., having depression and an alcohol use disorder), there are no hard-and-fast rules that define what psychological disorder will be paired with what substance use disorder.
As mentioned above, people who have co-occurring disorders present specific challenges in treatment. Research regarding treatment options for these individuals indicates that both disorders need to be treated concurrently in order for progress to be made in the treatment of either disorder. Integrated treatment is a model of treatment that uses multidisciplinary teams and a multidisciplinary approach to treat all of the issues that these individuals present with at the same time. The multidisciplinary team works together to make sure that each treatment program adheres to the principles of empirically validated treatment approaches, yet at the same time is adjusted to the specific case. The goals of integrated treatment are to:
- Develop a strong working alliance between the team and the client: This working alliance represents the commitment and level of trust between therapists, counselors, physicians, and other involved parties and the client regarding the specific goals of treatment.
- Help the client become more autonomous: Ultimately, the goal is for clients to be as self-sufficient as possible.
- Build the client’s skills: This involves the instruction and practice of specific skills that are needed to manage the particular situation.
- Develop goals, approaches, and strategies to continue long-term improvement: Often, this facet of the program is accomplished by ongoing treatment and support that last for years.
The multidisciplinary team consists of physicians, therapists and counselors, social workers, case managers, vocational counselors, occupational therapists, and any other treatment professionals who are needed in the specific case. Treatment protocols should follow standard approaches that are adjusted to fit the needs of the individual. These include:
- Detox:Medical detox will assist the individual in safely negotiating any withdrawal symptoms that are associated with the substance use disorder. This can include a tapering strategy and/or the use of medications. Medication use is dependent on the particular substance use disorder. Medications like Suboxone could be used for individuals with narcotic medication use disorders, supervised use of benzodiazepines could be used for individuals with alcohol use disorders, and tapering strategies using benzodiazepines could be used for individuals with benzodiazepine use disorders.
- Intensive therapy: This is always a component of a treatment plan for co-occurring disorders. The therapy can be delivered as individual therapy, group therapy, or a combination of individual or group therapy. Both the substance use disorder and the psychological disorder are targeted in therapy.
- Continued medical management: This may be appropriate for the individual’s psychological disorder and to deal with cravings for drugs can be ongoing.
- Support group participation: This can allow individuals to share their experiences, frustrations, successes, and other information with one another in addition to developing strategies and getting support to deal with their issues. Well-known 12-Step groups, such as Alcoholics Anonymousand Narcotics Anonymous, are commonly incorporated into treatment programs. There is also a special 12-Step group, Double Trouble in Recovery, specifically designed for individuals with dual diagnoses. Other types of support groups, such as SMART Recovery, can also be used. Social support groups like these can be components of long-term aftercare.