What Are Co-Occurring Disorders?

Substance abuse and mental health conditions do not exist in vacuums. They are products of genetics, personality, environment, and a number of other factors, some of which can be controlled, and some that cannot be controlled. They can also be products of each other; a substance abuse problem can lead to a mental health condition, and a mental health problem can lead to an addiction. When they present in combination, the conditions are referred to as co-occurring disorders.

Where Drug Abuse and Mental Health Meet

Dramatic image of a sad teenage girl crying

The Substance Abuse and Mental Health Services Administration explains that almost 9 million people suffer from co-occurring disorders, wherein they abuse drugs or alcohol because of their mental health condition, or their condition compels them to abuse drugs or alcohol. Psych Central quotes the National Alliance on Mental Illness as saying that 50 percent of people who have “severe” mental illnesses take some form of drugs or alcohol as self-medication.

In the same way that no two mental health conditions are the same, no two substance abuse conditions are identical. There are some combinations that are experienced more frequently than others; however different variations of co-occurring disorders can manifest in a person depending on a number of circumstances. According to Slate magazine, these factors can include:

  • Genetics
  • Individual psychological composition (especially with regards coping skills to deal with trauma and stress)
  • Previous experience(s) with the controlled substances (or prescription medications)
  • Environment
  • Predispositions towards impulsive behavior

As important as the genetic component is, genes alone do not decide whether or not a person will develop a substance abuse problem if a mental health disorder is present, or vice versa. Instead, a family history of one or the other (or both) only suggests a greater chance of a substance abuse or mental health disorder arising, if other factors are also present.

Biological and Emotional Vulnerabilities

The balance is expressed in what is known as the stress-vulnerability model, which attempts to conceptualize the paradigm of co-occurring disorders in terms of the biological and stress factors that combine to lay the foundations for a dual substance abuse and mental health disorder. Biological vulnerability, for example, considers whether a person is at risk for developing a mental health disorder because of physical conditions, such as asthma or diabetes.

It is also possible to be biologically vulnerable to psychiatric disorders. This itself can be determined by a number of factors; genetics is one of them, but also prenatal nutrition, physical and psychological wellbeing of the mother, birth complications, and traumatic experiences in early childhood (such as abuse, neglect, or the loss of a parent, whether by divorce or death).

The presence of stress factors, such as financial hardship, relationship struggles, or lack of meaningful activities and interests, can increase the biological vulnerability of a person, exacerbating symptoms of a mental health disorder and causing a relapse into substance abuse.

Stress can also result from seemingly positive life events, such as having a baby or landing a dream job; both these events can place enormous demands on time and stamina, and push hobbies or other interests to the background, thereby causing its own brand of stress. US News & World Report, for example, writes that 90 percent of couples struggled with their relationship after the birth of their first child.

According to the National Alliance on Mental Illness, men are more likely to develop co-occurring disorders than women. This may be because men are three times more prone to taking risks and engaging in self-destructive behavior than women, even as women are more prone to developing mental health conditions like depression and stress.

Some other at-risk populations include: military veterans, because the trauma of their combat experiences may cause them to experience stress-related disorders that they try to self-medicate with addictive substances; and people who grew up in with a lower economic status. The Duke University School of Medicine found that economic difficulties experienced in childhood could deprive adults of self-control and healthy choices, leading to stress and substance abuse.

Antisocial Personality Disorder

Notwithstanding the myriad combinations of environment, genetics, psychological composition, quality of life, and other factors that can bring a substance abuse issue and a mental health problem together, there tend to be some usual pairings. For example, the National Institute on Alcohol Abuse and Alcoholism has found that people with alcoholism are 21 times more likely to receive a diagnosis of antisocial personality disorder.

Antisocial personality disorder is a mental health disorder, where a person has no concern for the rule of law, concepts of right or wrong, or the wellbeing of other people.

People who have antisocial personality disorder have no concept of empathy; instead, they consider themselves to be of supreme importance, and real-life obligations or responsibilities have no meaning to them. For this reason, people with antisocial personality disorder find it very difficult to hold down jobs or maintain relationships.

Certain symptoms of antisocial personality disorder – such as a compulsion to engage in impulsive behavior and not having any regard for personal safety or health – make the development of a substance abuse problem a significant likelihood. Similarly, an alcohol addiction compels individuals to lie about their drinking and spending habits, in a very similar way that people with antisocial personality disorder will pathologically lie, sometimes for no tangible reason.

The two-way relationship between alcoholism and antisocial personality disorder is not coincidental. NIAAA explains that alcoholism can exacerbate or speed up the development of antisocial personality disorder in an at-risk person, perhaps even forcing greater ASD symptoms than if the person had not consumed alcohol.

Cocaine and Psychiatric Disorders

Cocaine is a highly addictive stimulant that targets the brain. In doing so, it can cause up to 10 different psychiatric disorders. Medscape quotes the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders in listing some of them:

  • Delusions: steadfastly holding on to incorrect beliefs, even when evidence to the contrary is presented; this may present itself as people refusing to believe that cocaine is ruining their lives, instead fixating on sensations of power and charisma that cocaine provides
  • Hallucinations: imaginary audio or visual sensations that are so strong the person is convinced they are real; this, in itself, is a form of cocaine-induced psychosis
  • Mood disorders: similar to bipolar disorder, where the person is either manic, depressed, or in a state where neither mania or depression are dominant, and thus experiences a loss of interest in daily activities, weight changes, fatigue, or an inability to concentrate
  • Anxiety: panic attacks, anxiety attacks, obsessions, or compulsions

In researching the topic of “Cocaine and Psychiatric Symptoms,” the Journal of Clinical Psychiatry discovered that symptoms of paranoia (unreasonable distrust of others, to the point of delusions of persecution) were experienced in 68-84 percent of cocaine users. A study reviewed by the Journal reported that seven people who had lethal doses of cocaine were violently delirious, their behavior requiring them to be forcibly restrained for their own safety.

The Journal explains that cocaine’s addictiveness – which comes from how it affects the nervous system, hijacking the brain’s pleasure and rewards center – is so powerful that its effects are equal parts psychological as biological. This can either cause mental illness symptoms or provoke pre-existing conditions into full-blown disorders.

Opioids and Post-Traumatic Stress Disorder: A ‘Significant’ Association

A big meeting point between substance abuse and a mental health disorder is when an opioid addiction crosses paths with post-traumatic stress disorder. According to the U.S. Department of Veterans’ Affairs, 6.8 percent of adult Americans suffer from PTSD, a process of stress reactions that occur after people experience, or witness, an event that threatens their sense of safety or wellbeing. The event can be anything from witnessing a murder to surviving a car crash, and the reactions can last for a lifetime, often taking the form of:

  • Compulsively avoiding places, events, or people that cause the person to involuntarily remember the initial traumatic event
  • Hyperarousal, being constantly tense, alert, and on edge that the event might happen again
  • Intrusive thoughts, where everyday life is disrupted because the person experiences unbidden and recurring flashbacks and nightmares of the experience

As with other examples of co-occurring disorders, those who have both post-traumatic stress disorder and a dependence on opioids have a meeting point of symptoms. Similar to how PTSD causes agitation in its sufferers, a dependence on opioids (either recreational or prescription) show comparable signs of discomposure as a result of the effect the drugs have on the body.

In 2014, the American Journal of Drug and Alcohol Abuse surveyed 573 people who were receiving treatment for substance abuse and found that of those people who were addicted to prescription opioids (for the treatment of chronic pain, for example) were more likely to develop post-traumatic stress disorder. The researchers wrote that there was a “significant” association between the consumption of prescription opioids and the severity of co-occurring PTSD symptoms. Furthermore, “being female” increased the chances of this co-occurring disorder developing. Women have an elevated response to fear or stressful stimuli, which the Journal of Psychiatric Research says makes them twice as likely as men to develop PTSD. This therefore raises the likelihood of women abusing (prescription) opioids, which further increases the chances of developing post-traumatic stress disorder.

Treatment for Co-Occurring Disorders

The Substance Abuse and Mental Health Services Administration explains some of the big-picture goals of the integrated treatment model:

  • Individuals better understand how their substance abuse or behavioral issues impact themselves and the world around them.
  • Friends and family are part of the treatment process.
  • Improvement is framed in terms of realistic, achievable and challenging goals, such as holding down a job, becoming involved in the community, and other endeavors that can help them rebuild their day-to-day lives.

Since co-occurring disorders have to be addressed on multiple fronts, treatment needs to combine substance abuse therapy and mental health recovery. To this effect, the integrated treatment model often uses the overlap of the therapeutic and 12-Step approach for the addiction and established methods of improving mental health, to help the person work on both conditions. Both the substance abuse and the mental health dynamics are considered illnesses, with each needing specific and similar remedies to first deal with the symptoms of the co-occurring disorders, and then the underlying issues behind the drug or alcohol abuse and mental health concern.

One tactic of the integrated treatment model is that is teaches the person about the relationship between the addiction and the mental or behavioral disorders. The journal of Hospital and Community Psychiatry explains that the idea behind this education is to give patients tools and insights into how they can (with the help of their therapists, family members, and aftercare support networks) deal with stressful situations in a much more positive and beneficial way. This can mean devising some coping strategies to endure or overcome stress in such a way that does not involve consuming alcoholic beverages, or building up mindful thought patterns to protect against depressive or anxiety-based impulses.

Even though the integrated model of treating co-occurring disorders is a combination of methodology from both substance abuse and mental health models, it contains specific dynamics to counsel those with co-occurring disorders (for example, longer durations of treatment, and, with the possibility of the mental health disorder triggering a relapse, a slower, more methodical progression).

This is largely because co-occurring disorders tend to cause more severe symptoms (in terms of length or severity), as opposed to those who experience substance abuse or mental health in isolation of each other. A person who is suffering from a co-occurring disorder would need to be referred to a healthcare practitioner who can recognize that the increased symptoms on display are caused by the conflation of a substance abuse and mental health disorder, and then engage the appropriate processes of the integrated treatment model.

For example, consider the case of a person presenting with alcoholism and antisocial personality disorder, which was discussed earlier. As much as the integrated treatment model looks to show the person how the conditions and behavior have changed the world around that person, those with antisocial personal disorder have no perspective or awareness of anyone but themselves. For reasons like these, the integrated treatment model has to be intensive.

To that effect, the integrated treatment model offers a combination of medication as well as psychological, educational, and social approaches, so that every part of the person’s life is addressed and improved. Such methods take time, but they are far more successful than working on the disorders in isolation (which used to be the norm).

Family members and loved ones should make it a point to search for a treatment center that is staffed by professionals who have specific training and licensing in co-occurring disorders (also known as a dual diagnosis), not exclusively substance abuse or mental health rehabilitation. This will greatly increase the chances of the person receiving the necessary and precise treatment needed to control harmful impulses and to begin the process of long-term recovery.

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Editorial Staff
Editorial Staff, American Addiction Centers
The editorial staff of Greenhouse Treatment Center is comprised of addiction content experts from American Addiction Centers. Our editors and medical reviewers have over a decade of cumulative experience in medical content editing and have reviewed... Read More