WHAT DOES DUAL DIAGNOSIS
OR CO-OCCURRING DISORDER MEAN?
A person who has both an alcohol or drug problem and an emotional/psychiatric problem is said to have a dual diagnosis. To recover fully, the person needs treatment for both problems
HOW COMMON IS DUAL DIAGNOSIS?
Dual diagnosis is more common than you might imagine. According to a report published by the Journal of the American Medical Association:
Thirty-seven percent of alcohol abusers and fifty-three percent of drug abusers also have at least one serious mental illness.
Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.
WHAT KIND OF MENTAL OR EMOTIONAL PROBLEMS ARE COMMONLY SEEN IN PEOPLE WITH DUAL DIAGNOSIS?
The following psychiatric problems commonly occur as a dual diagnosis – i.e., in tandem with alcohol or drug dependency.
Depressive disorders, such as depression and bipolar disorder
Anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias
HOW CAN A PROFESSIONAL TELL WHETHER THE PERSON’S PRIMARY PROBLEM IS SUBSTANCE ABUSE OR AN EMOTIONAL DISORDER?
At the initial examination, it may be difficult to tell. Since many symptoms of severe substance abuse mimic other psychiatric conditions, the person must go through a withdrawal from alcohol and/or drugs before the physician can accurately assess whether there’s an underlying psychiatric problem also.
IF A PERSON DOES HAVE BOTH AN ALCOHOL/DRUG PROBLEM AND AN EMOTIONAL PROBLEM, WHICH SHOULD BE TREATED FIRST?
Ideally, both problems should be treated simultaneously. For any substance abuser, however, the first step in treatment must be detoxification – a period of time during which the body is allowed to cleanse itself of alcohol or drugs. Ideally, detoxification should take place under medical supervision. It can take a few days to a week or more, depending on what substances the person abused and for how long.
Until recently, alcoholics and drug addicts dreaded detoxification because it meant a painful and sometimes life-threatening “cold turkey” withdrawal. Now, doctors are able to give hospitalized substance abusers carefully chosen medications which can substantially ease withdrawal symptoms. Thus, when detoxification is done under medical supervision, it’s safer and less traumatic.
WHAT HAPPENS AFTER DETOX?
Once detoxification is completed, it’s time for dual treatment; rehabilitation for the alcohol or drug problem and treatment for the psychiatric problem.
Rehabilitation for a substance abuse problem usually involves individual and group psychotherapy, education about alcohol and drugs, exercise, proper nutrition, and participation in a 12-step recovery program such as Alcoholics Anonymous. The idea is not just to stay off booze and drugs, but to learn to enjoy life without these “crutches.”
Treatment for a psychiatric problem depends upon the diagnosis. For most disorders, individual and group therapy as well as medications are recommended. Expressive therapies and education about the particular psychiatric condition are often useful adjuncts. A support group of other people who are recovering from the same condition may also prove highly beneficial. Adjunct treatment, such as occupational or expressive therapy, can help individuals better understand and communicate their feelings or develop better problem-solving or decision-making skills.
MUST A CO-OCCURRING DISORDER PATIENT BE TREATED IN A HOSPITAL?
Not necessarily. The nature and severity of the illness, the associated risks or complications, and the person’s treatment history are some of the facts considered in determining the appropriate level of care. There are several different levels or intensities of care including full hospitalization or inpatient treatment, partial hospitalization, and outpatient treatment.
WHAT IS A MOOD DISORDER?
Mood disorder is the term given for a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR) classification system where a disturbance in the person’s mood is hypothesized to be the main underlying feature. The classification is known as mood (affective) disorders in ICD 10.
English psychiatrist Henry Maudsley proposed an overarching category of affective disorder. The term was then replaced by mood disorder, as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.
Two groups of mood disorders are broadly recognized; the division is based on whether the person has ever had a manic or hypomanic episode. Thus, there are depressive disorders, of which the best known and most researched is major depressive disorder (MDD) commonly called clinical depression or major depression, and bipolar disorder (BD), formerly known as manic depression and described by intermittent periods of manic and depressed episodes.
Major depressive disorder (MDD), commonly called major depression, unipolar depression, or clinical depression, is a mood disorder where the person has one or more major depressive episodes. After a single episode, Major Depressive Disorder (single episode) would be diagnosed. After more than one episode, the diagnosis becomes Major Depressive Disorder (Recurrent). Depression without periods of mania is sometimes referred to as unipolar depression because the mood remains at one emotional state or “pole”.
Individuals with a major depressive episode or major depressive disorder are at increased risk for suicide. Seeking help and treatment from a health professional dramatically reduces the individual’s risk for suicide. Studies have demonstrated that asking if a depressed friend or family member has thought of committing suicide is an effective way of identifying those at risk, and it does not “plant” the idea or increase an individual’s risk for suicide in any way.
Bipolar disorder (BD) is a mood disorder formerly known as “manic depression” and described by alternating periods of mania and depression (and in some cases rapid cycling, mixed states, and psychotic symptoms). Subtypes include:
* Bipolar I is distinguished by the presence or history of one or more manic episodes or mixed episodes with or without major depressive episodes. A depressive episode is not required for the diagnosis of Bipolar I disorder, but depressive episodes are often part of the course of the illness.
* Bipolar II consisting of recurrent intermittent hypomanic and depressive episodes.
* Cyclothymia is a different form of bipolar disorder, consisting of recurrent hypomanic and dysthymic episodes, but no full manic episodes or full major depressive episodes.
* Bipolar Disorder Not Otherwise Specified (BD-NOS), sometimes called “sub-threshold” bipolar, indicates that the patient suffers from some symptoms in the bipolar spectrum (e.g. manic and depressive symptoms) but does not fully qualify for any of the three formal bipolar DSM-IV diagnoses mentioned above.
It is estimated that roughly one percent of the adult population suffers from bipolar I, roughly one percent of the adult population suffers from bipolar II or cyclothymia
SUBSTANCE ABUSE INDUCED MOOD DISORDERS
A mood disorder can be classified as substance-induced if its etiology can be traced to the direct physiologic effects of a psychoactive drug or other chemical substance, or if the development of the mood disorder occurred contemporaneously with substance intoxication or withdrawal. Alternately, an individual may have a mood disorder coexisting with a substance abuse disorder. Substance-induced mood disorders can have features of a manic, hypomanic, mixed, or depressive episode. Most substances can induce a variety of mood disorders. For example, stimulants such as amphetamine (Adderall, Dexedrine; “Speed”), methamphetamine (Desoxyn; “Meth”, “Crank”, “Crystal”, etc.), and cocaine (“Coke”, “Crack”, etc.) can cause manic, hypomanic, mixed, and depressive episodes.
ALCOHOL INDUCED MOOD DISORDERS
High rates of major depressive disorder occur in heavy drinkers and those with alcoholism. Controversy has previously surrounded whether those who abused alcohol and developed depression were self-medicating their pre-existing depression, but recent research has concluded that, while this may be true in some cases, alcohol misuse directly causes the development of depression in a significant number of heavy drinkers. High rates of suicide also occur in those who have alcohol-related problems. It is usually possible to differentiate between alcohol-related depression and depression which is not related to alcohol intake by taking a careful history of the patient. Depression and other mental health problems associated with alcohol misuse may be due to distortion of brain chemistry, as they tend to improve on their own after a period of abstinence
BENZODIAZEPINE INDUCED MOOD DISORDERS
Long term use of benzodiazepines can have a similar effect on the brain as alcohol and are also associated with depression. Major depressive disorder can also develop as a result of chronic use of benzodiazepines or as part of a protracted withdrawal syndrome. Benzodiazepines are a class of medication which are commonly used to treat insomnia, anxiety and muscular spasms. As with alcohol, the effects of benzodiazepine on neurochemistry, such as decreased levels of serotonin and norepinephrine, are believed to be responsible for the increased depression. Major depressive disorder may also occur as part of the benzodiazepine withdrawal syndrome. In a long-term follow-up study of patients dependent on benzodiazepines, it was found that 10 people (20%) had taken drug overdoses while on chronic benzodiazepine medication despite only two people ever having had any pre-existing depressive disorder. A year after a gradual withdrawal program, no patients had taken any further overdoses. Depression resulting from withdrawal from benzodiazepines usually subsides after a few months but in some cases may persist for as long as 6–12 months.
What is “Personality?”
Personality can be described as a specific set of behavior traits, reactive styles and patterns that become “hard wired” into our character. Personality can be also be described as how we look at the world and people around us, our attitudes, feelings and how we communicate in our private and professional lives. Not being “hard wired” to react or act in a specific way when faced with the difficulties and challenges presented in every day living allows one’s personality to be “fluid” or bendable – ready to cope with stressors in a way that does not seem extreme or constricted. People with healthy personalities have less difficulty contending with stress and find it easier to form long lasting relationships.
For many people suffering from addiction, there may be a personality disorder that is either driving the addiction or vice versa.
What is a Personality Disorder?
People who live with a personality disorder (or personality disorder traits), find their interpersonal relationships extremely difficult. Whether narcissistic, borderline, histrionic, anti-social or schizoid, these people all contain a deeply ingrained, inflexible pattern of relating to others and to themselves. Depending on the disorder, varying symptoms will predominate and at times will be serious enough to cause significant dysfunction.
What Causes a Personality Disorder?
Theories vary on what causes a personality disorder (nature vs. nurture) and what kind of treatment best suits a particular disorder. The types of personality disorders fall into three different categories known as “clusters.”
* Cluster A: Odd or eccentric behavior
* Cluster B: Dramatic, emotional or erratic behavior
* Cluster C: Anxious fearful behavior
Below is a review of each cluster:
CLUSTER A: Odd or eccentric behavior
Schizoid Personality Disorder. Schizoid personalities are introverted, withdrawn, solitary, emotionally cold, and distant. They are often absorbed with their own thoughts and feelings and are fearful of closeness and intimacy with others. For example, a person suffering from schizoid personality is more of a daydreamer than a practical action taker.
Paranoid Personality Disorder. The essential feature for this type of personality disorder is interpreting the actions of others as deliberately threatening or demeaning. People with paranoid personality disorder are untrusting, unforgiving, and prone to angry or aggressive outbursts without justification because they perceive others as unfaithful, disloyal, condescending or deceitful. This type of person may also be jealous, guarded, secretive, and scheming, and may appear to be emotionally “cold” or excessively serious.
Schizotypal Personality Disorder. A pattern of peculiarities best describes those with schizotypal personality disorder. People may have odd or eccentric manners of speaking or dressing. Strange, outlandish or paranoid beliefs and thoughts are common. People with schizotypal personality disorder have difficulties forming relationships and experience extreme anxiety in social situations. They may react inappropriately or not react at all during a conversation or they may talk to themselves. They also display signs of “magical thinking” by saying they can see into the future or read other people’s minds.
Antisocial Personality Disorder. People with antisocial personality disorder characteristically act out their conflicts and ignore normal rules of social behavior. These individuals are impulsive, irresponsible, and callous. Typically, the antisocial personality has a history of legal difficulties, belligerent and irresponsible behavior, aggressive and even violent relationships. They show no respect for other people and feel no remorse about the effects of their behavior on others. These people are at high risk for substance abuse, especially alcoholism, since it helps them to relieve tension, irritability and boredom.
Borderline Personality Disorder. People with borderline personality disorder can be unstable in a variety of ways. Depending on the severity, they may experience great fluctuations in mood, behavior and unpredictable or self-destructive behaviors including addiction, eating disorders, self mutilation and suicide attempts/ideation. Feelings of emptiness pervade along with a sense of not really knowing who they are as well as a pattern of shaky relationships and impulsivity.
Narcissistic Personality Disorder. People with narcissistic personality have an exaggerated sense of self-importance, are absorbed by fantasies of unlimited success, and seek constant attention in spite of a deep seated feeling of worthlessness and emptiness. The narcissistic personality is oversensitive to failure and often complains of multiple somatic symptoms. Prone to extreme mood swings between self-admiration and insecurity, these people tend to exploit interpersonal relationships and may fall into malignant or benign categories.
Avoidant Personality Disorder. Avoidant personalities struggle with extreme sensitivity to rejection and tend to avoid relationships that may be ambiguous. These people tend to be severely uncomfortable in social situations and may be fearful of how they appear in relation to others. They crave relationships, but find it so distressing to engage that they will isolate or only engage in familial relationships.
Dependent Personality Disorder. These people may be living with a pattern of dependent and submissive behavior, relying on others to make decisions for them. They require excessive reassurance and advice, and are easily hurt by criticism or disapproval. They feel uncomfortable and helpless if they are alone, and can be devastated when a close relationship ends. They have a strong fear of rejection. Typically lacking in self-confidence, the dependent personality rarely initiates projects or does things independently. This disorder usually begins by early adulthood and is diagnosed more frequently in females than males.
Obsessive-Compulsive Personality Disorder. Compulsive personalities are conscientious and have high levels of aspiration, but they also strive for perfection. Never satisfied with their achievements, people with compulsive personality disorder take on more and more responsibilities. They are reliable, dependable, orderly, and methodical, but their inflexibility often makes them incapable of adapting to changed circumstances. People with compulsive personality are highly cautious, weigh all aspects of a problem, and pay attention to every detail, making it difficult for them to make decisions and complete tasks. When their feelings are not under strict control, events are unpredictable, or they must rely on others, compulsive personalities often feel a sense of isolation and helplessness.
When these characteristics are carried to an extreme, when they endure over time and when they interfere with healthy functioning, a diagnostic evaluation with a licensed physician or mental health professional is recommended.
Treatment of the Personality Disorder
There are many types of help available for the different personality disorders. Treatment may include individual, group, or family psychotherapy. Medications, prescribed by a patient’s physician, may also be helpful in relieving some of the symptoms of personality disorders, including problems with anxiety and perceptions.
Psychotherapy for patients with personality disorders focuses on helping them see the unconscious conflicts that are contributing to or causing their symptoms. It also helps people become more flexible and is aimed at reducing the behavior patterns that interfere with everyday living.
In psychotherapy, people with personality disorders can better recognize the effects of their behavior on others. Behavior and cognitive therapies focus on resolving symptoms or traits that are characteristic of the disorder, such as the inability to make important life decisions or the inability to initiate relationships.
There is Hope
The more you learn about personality disorders the more you will understand that they are illnesses, with causes and treatments. People can improve with proper care. By seeking out information you can recognize the signs and symptoms of a personality disorder and help yourself or someone you know live a healthier more fulfilling life.
At Journey Malibu, our expert staff can diagose and treat addiction when it is also coupled with a personality disorder.