Dual Diagnosis Treatment
Dual diagnosis is the term used to define the existence of a substance use disorder and a comorbid mental health disorder. According to the 2014 National Survey on Drug Use and Health, nearly 8 million Americans struggle with a dual diagnosis. Put another way, about 25% of individuals with a substance use disorder also have a co-occurring mental health disorder.
When attempting to diagnose and treat individuals with a dual diagnosis, it is often difficult to discern which disorder emerged first, the mental health disorder, such as anxiety, depression, or bipolar disorder, or the substance use disorder.
Take for example co-occurring alcohol use disorder and depression. In this case, the individual may experience a major depressive episode and turn to alcohol as a means of self-medicating their emotional distress. Over time, the tolerance to alcohol increases, resulting in more excessive drinking and alcoholism may result. The depression was a precursor to the alcoholism. However, in other situations the individual may develop the alcohol problem first. Over time, as the negative consequences resulting from the alcohol addiction mount, depression sets in, indicating that alcoholism can trigger a depressive disorder.
Regardless of the order of the onset of each disorder, treatment for both disorders should be part of a integrated treatment program that attends to both disorders simultaneously for the best chance of success in recovery. This is because the mental health issue can present a risk factor for relapse. Without effectively treating the mental health disorder, the symptoms will simply undermine sobriety and relapse will result.
Obtaining professional treatment for a dual diagnosis is critical. There is a tendency for the symptoms and consequences of each of the disorders to become more serious, as the disorders amplify the effects of the other. Some of the resulting consequences of an untreated dual diagnosis include:
- Instability in relationships
- Impaired social functioning
- Financial fallout
- Poor health
- Elevated risk for suicide
Common Co-Occurring Disorders involving Alcohol Use Disorder
There is a tendency for alcohol abuse to coexist with mental health disorders. Three examples of co-occurring disorders involving alcohol include:
- Alcohol Use Disorder and Depression
Depression impacts more than 17 million Americans each year. Individuals who struggle with depression may lean on alcohol to help them numb the depression symptoms. The symptoms can be so difficult to bear that the alcohol provides some relief and a temporary escape from their present suffering. These include:
- Sadness, despair, hopelessness
- Loss of desire to participate in usual activities
- Weight loss or gain
- Insomnia or hypersomnia
- Slowed motor and cognitive functioning
- Inappropriate feelings of shame or guilt
- Trouble concentrating or making decisions
- Suicidal thoughts
The consequences of this dual diagnosis can be significant. Struggling with both depression and alcohol dependency can result in increased impulsivity and risk-taking behaviors, and neglecting work or family obligations.
Other consequences of the dual diagnosis of alcoholism and depression might include:
- Loss of job
- Loss of custody
- Financial consequences due to job loss
- Legal problems, such as getting a DUI
- Divorce or interpersonal relationship issues
- Health problems, such as liver disease, heart disease, pancreatitis, cancer
- Accidents that result in injury to self or others, or damaged property
PTSD and Alcoholism
Alcohol is the substance of choice for individuals suffering from post-traumatic stress disorder, or PTSD that wish to subdue the symptoms. Alcohol can set up an endorphin replacement cycle in the brain of someone who has suffered a traumatic event, producing a soothing, stress-relieving effect, at least at first. However, the emotional fallout caused by PTSD can lead to increased dependence on alcohol, setting up a vicious cycle that ultimately culminates in a dual diagnosis.
PTSD symptoms lasting more than three months include:
- Flashbacks, nightmares, or trauma-related triggers that cause the individual to replay the traumatic event over and over again.
- Avoiding places, situations, or people that provoke disturbing memories of the event.
- Hyperarousal, feeling jittery, easily excitable or startled
- Emotional numbness, detachment
- Angry outbursts
Bipolar Disorder and Alcohol Use Disorder
Bipolar disorder is a challenging mental health disorder, as both disorders have extremely negative effects on the other. Bipolar disorder, when paired with alcohol abuse, results in a co-occurrence that requires a long-term treatment approach to obtain some balance between episodes. The extreme mood swings that characterize bipolar disease include the following symptoms:
- Persistent sadness
- Intense fatigue
- Feelings of hopelessness and despair
- Sleep disturbances
- Loss of interest in life
- Chronic pain with no known medical cause
- Trouble concentrating
- Suicidal ideation
- Racing thoughts
- Rapid speech
- Aggressive behavior
- Decreased sleep
- Impulsive behaviors
- Risky behaviors
- Psychosis, including paranoia, delusions, or hallucinations
Other common dual diagnosis combinations include:
- Anxiety and benzodiazepines
- Social anxiety and cannabis abuse
- Schizophrenia and cannabis abuse
Comprehensive Treatment for Dual Diagnosis
The current best practices for dual diagnosis involves a full spectrum of therapeutic interventions that work simultaneously in an integrated approach to recovery. Both disorders must be carefully diagnosed before an appropriate treatment plan can be formulated. The plan should be individualized for each client’s unique dual diagnosis.
A program that specializes in dual diagnosis treatment will have a psychiatrist on staff. These mental health professionals will provide guidance to the addiction specialists in an ongoing manner, helping to manage unpredictable outbursts or mood swings that may occur during treatment.
Often, the individual must first be abstinent from the substance use for a minimum of two weeks before an accurate diagnosis of the mental health issue can be made. This is because the symptoms associated with a mental health disorder may actually be attributed to the addiction. Once the drug or alcohol has cleared the body and the individual has stabilized, a more accurate diagnosis can be made.
Medical and Psycho-social Interventions
The process of treating a dual diagnosis will encompass both medical and psychosocial interventions. The medial aspect involves the use of pharmacological assistance to help manage a mental health disorder, drugs such as antidepressants, anti-anxiety medications, mood stabilizers, or anti-psychotic drugs. Medication may also be warranted for managing early addiction recovery, including naltrexone, methadone, or buprenorphine.
The psychosocial piece of recovery assists the client in recovery to make changes in dysfunctional thought patterns that have kept them stuck in a cycle of substance abuse. In addition, psychosocial interventions help the individual:
- Improve overall functioning
- Reduce the risk of relapse
- Engage in recovery activities
- Improving interpersonal functioning
- Establish a structured daily routine
- Increase the motivation to make fundamental change.
Integrated treatment elements for dual diagnosis include:
Medically supervised detox and withdrawal: Alcohol detox should always be medically supervised, as potentially dangerous withdrawal symptoms can suddenly emerge. Detoxification is treated using benzodiazepines and other medications to ease symptoms.
Individual psychotherapy: Therapy is an essential core element for treating both disorders. The therapist will guide the individual to examine sources of emotional pain and help them resolve these. There may be unresolved trauma issues or a history of sexual or physical abuse that has contributed to the dual diagnosis. These issues must be explored so they can be processed and eventually healed.
Individual therapy also provides an opportunity for clients to identify how certain negative self-talk or thought distortions may lead to the substance use behaviors. Once these are acknowledged, the therapist can guide the client toward replacing the negative thoughts with affirming and productive thoughts.
Evidence-based psychotherapies include:
- Cognitive behavioral therapy. CBT helps shift addiction responses toward positive, productive behavioral responses, as well as teaching coping skills.
- Dialectical behavior therapy. DBT focuses on acceptance of the condition and embracing change through four strategies: Mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness.
- Motivational enhancement therapy. MET helps clients resolve feelings of ambivalence about discontinuing the substance abuse and embracing recovery.
Integrated group counseling. Integrated group therapy sessions involve small groups of individuals with similar dual diagnoses, such as those who struggle with anxiety and alcohol use disorder, who are encouraged to share about their struggles, frustrations, fears, and other relatable emotions. Group therapy supports peer interaction and is a source for sharing and accountability for individuals in therapy.
Recovery community meetings. Many dual diagnosis programs weave the 12-step or similar recovery philosophy into the programming. The program may incorporate A.A., N.A. or “Double Trouble in recovery” (DTR), a 12-step offshoot designed specifically for individuals with a dual diagnosis.
Medication management. Medications are generally a core treatment element for a dual diagnosis. Pharmacotherapy is used to help stabilize the manifestations of the mental health disorder, which allows for better engagement in both the addiction recovery and the psychiatric therapy. In addition, medication-assisted treatment (MAT) is sometimes appropriate for some substance use disorders. These drugs can help reduce the risk of relapse, thereby sustaining sobriety.
Relapse Prevention: Addiction specialists will assist clients in creating a detailed relapse prevention strategy. The client will identify specific triggers or situations that could lead to relapse, and outline a plan of actionable steps to prevent it from occurring. Recovery skills are taught to provide the tools to help prevent relapse.
Continuing care services: Following completion of a dual diagnosis program, it is essential that continuing care services are included in aftercare strategies. These help individuals to weather the challenges that are prevalent during early recovery, and stay on track. People find that making the transition to regular life following rehab can be difficult, so prioritizing recovery through aftercare efforts is important. Continuing care services include weekly outpatient therapy, engagement in a recovery community, getting regular exercise, and possibly transitioning to sober living immediately after rehab if the home environment is not supportive of recovery efforts.