Co-occurring Disorders

What are co-occurring disorders?

The term “co-occurring disorders” refers to an individual who has a substance use disorder and a mental health disorder at the same time. “Dual diagnosis” and “dual disorders” are older terms for co-occurring disorders.

The American Psychiatric Association (APA) uses the term “substance use disorder” to define a pattern of use of alcohol or other drugs that leads to significant physical, interpersonal, medical, or work problems. Substance use disorder is further broken down into drug-specific use disorders, such as alcohol use disorder or stimulant use disorder, depending on the specific drug and its qualities. Substance use disorder is rated as mild, moderate, or severe based on how many criteria are met. A person diagnosed with a substance use disorder can also be classified as in remission, or what is commonly referred to as “in recovery.”

People are diagnosed with a mental health (or psychiatric) disorder when they experience problems with feelings, thinking, functioning, or relationships that are not due to alcohol or other drug use and are not the result of a medical illness.

Some common mental health disorders are

anxiety disorders, such as generalized anxiety disorder, social anxiety disorder, and panic disorder
obsessive-compulsive disorder (OCD)
trauma- and stress-related disorders, such as post-traumatic stress disorder (PTSD)
mood disorders such as major depression and dysthymia
bipolar disorder
personality disorders
schizophrenia and other psychotic disorders

When people are diagnosed as having co-occurring disorders, it means that they have both a substance use disorder and a mental health disorder at the same time, or at least have had both during the past year. Sometimes people have more than one mental health disorder or more than one substance use disorder.

Because substance use disorders and mental health disorders often recur, most experts consider anyone who has had a substance use disorder and a mental health disorder in his or her lifetime to have co-occurring disorders. A comprehensive screening and assessment will determine if a person has a substance use disorder and one or more mental health disorders.

What is not considered co-occurring disorders?

The phrase “co-occurring disorders” does not apply to people who have a substance use disorder and some mood or relationship problems. Nor does it apply to people who have a mental health disorder and some problems related to substance use.

Of the people with a substance use disorder, about 60 to 70 percent have or had a mental health disorder. Of the people with a mental health disorder, 25 to 50 percent have or had a substance use disorder. Thus, co-occurring disorders are common, but not everyone with a substance use or mental health disorder has one. People with substance use disorders may have emotional problems such as depression, anxiety, or post-traumatic symptoms, but these may be normal responses to certain life events. People with mental health disorders may drink alcohol or use drugs. But if their use is not problematic, they do not have co- occurring disorders.

What common problems are related to co-occurring disorders?

Co-occurring disorders can cause a wide variety of problems, depending on the specific substance use and mental health disorders people have.

Common problems relating to co-occurring disorders include

use of alcohol or other drugs to reduce the difficulty or pain associated with psychiatric problems, which may work in the short term but usually backfires in the long run
a mental health disorder that is worsening because of alcohol or other drug use
a substance use disorder that is worsening because of psychiatric problems
difficulty getting treatment for both disorders or difficulty benefiting from treatment
difficulty finding supportive people who understand both disorders

What is the cause of co-occurring disorders?

There appear to be common genetic risk factors for substance use and certain mental health disorders, but genes alone cannot explain all cases of co-occurring disorders. Other factors include family, environment, and life stress, including traumatic life events, poverty, and early loss of significant others. In fact, these stressful experiences may trigger genetic factors that contribute to co-occurring disorders. Research has confirmed that both substance use and mental health disorders have a neurological basis, which is why they are now commonly referred to as “brain diseases.”

It is not known why people become addicted to a certain substance and not another. Some research indicates that access and exposure to substances may be the most important reason. That is, the substances people have access to determine the type of substance use disorder.

People with a mental health disorder may be more biologically sensitive to the effects of substances. They may also use substances to cope with symptoms, such as alleviating social anxiety. In general, people who have a mental health disorder are at much greater risk of also having a substance use disorder. People who have a substance use disorder are at much greater risk of also developing a mental health disorder. People who developed a substance use disorder when they were relatively young before their brain was fully developed may not have learned good coping skills and ways of dealing with life. This may have left them vulnerable to developing a mental health disorder.

How does the use of alcohol and other drugs affect a co-occurring mental health disorder?

People with a mental health disorder often use substances to feel better. They may think a drink will cheer them up. People who are anxious may want something to make them feel calm; people who are depressed may want something to make them feel more animated; people who are fearful of others may want something to make them feel more relaxed and less inhibited; and people who are in psychological pain may want something to make them feel numb.

Using alcohol or other drugs often develops into a substance use disorder. It not only fails to repair the mental health disorder but also prevents people from developing effective coping skills, having satisfying relationships, and feeling comfortable with themselves. In short, drug and alcohol use makes mental health disorders worse.

How does a mental health disorder affect addiction treatment and recovery?

Having a mental health disorder can make people more sensitive to the effects of substance use. The consequences from binge drinking or chronic long-term use can happen more rapidly. With the best of intentions, people with a mental health disorder may try to stop using substances. However, sometimes when the substance use stops, the symptoms of the mental health disorder return or worsen. These people may wonder why they should bother trying to get clean and sober. If they manage to get into treatment, they might find that they are judged and even criticized for their psychiatric symptoms.

A few treatment professionals may even hint that if only patients were more honest and tried hard, their psychiatric symptoms would disappear with good recovery work. In short, psychiatric problems make substance use disorders worse.

Today, it is commonly understood that the best treatment approach is one that helps people recover by offering mental health and substance abuse services at the same time and in one setting. This service is called integrated treatment.

What is integrated treatment for co-occurring disorders?

Effective treatment for co-occurring disorders has been developed only recently. In the past, many people with co-occurring disorders received inadequate care. Treatment professionals failed to understand that treating one disorder would not cause the other disorder to automatically improve. Integrated treatment, however, treats both disorders at the same time.

Integrated treatment can stabilize the symptoms of co-occurring disorders and provide the foundation for lasting recovery from substance use and mental health disorders.

Integrated treatment involves a combination of the following:

accurate detection and diagnosis of both disorders
education about substance use and mental health disorders, their inter- action, and the options for treatment
exploration of the individual’s motivation and commitment to address his or her substance use and psychiatric problems
therapies, including cognitive-behavioral therapy (CBT) that teach new skills and provide new insights
appropriate use of medication, e.g., antidepressants for depression and buprenorphine to reduce cravings
involvement of significant others in treatment, including opportunities for education and skill development
ongoing and frequent recovery check-ups, which monitor for the return of psychiatric symptoms and substance use

People with co-occurring disorders can benefit from attending peer support groups. Groups based on the Twelve Steps include Dual Recovery Anonymous and Double Trouble in Recovery.

Web resources

There are many resources out there. The websites for the following organizations were chosen for their usefulness and user friendliness.

National Institute of Mental Health (NIMH): NIMH is a U.S. government organization, an agency of the Department of Health and Human Services, dedicated to research and education in the field of mental health. Its website is a great resource of information about specific mental health disorders including ADHD, depression, anxiety disorders, and others.

National Institute on Alcohol Abuse and Alcoholism (NIAAA): A branch of the National Institutes of Health, the NIAAA supports and conducts research on the impact of alcohol use on human health and well-being. Its website offers many articles about alcohol, addiction, treatment, and co-occurring disorders.

National Institute on Drug Abuse (NIDA) This government organization is dedicated to addiction research and education. Through its website you can access up-to-date publications about many different drugs of abuse as well as emerging trends.