Co-occurring Disorders

More than five million people have co-occurring (comorbid) disorders. They are usually under-diagnosed and under-treated.

A person with co-occurring disorders, also known as a dual diagnosis, has two or more diagnoses or disorders. This may include signs and symptoms related to mental health, substance abuse, or a medical condition. For example, a person may have:

• Chronic pain, abuse of prescription medicine, and substance abuse.
• Depression, anxiety, and alcohol use.
• A learning disorder and communication disorder.
• Attention Deficit Hyperactivity Disorder (ADHD) and substance abuse.
• ADHD, an Autism Spectrum Disorder (ASD), and an anxiety disorder.
• Fetal Alcohol Spectrum Disorder (FASD) and a learning disorder.
• Conduct Disorder and Adjustment Disorder.

Although BHA/Ps are not expected to diagnose mental disorders, we should familiarize ourselves with mental disorders that co-occur with substance use disorders and that copy or mimic substance use disorders symptoms, such as withdrawal or intoxication.

Many people suffer from more than one disorder and their symptoms may have roots in one or more cause. There are some groups of people with personal factors that increase their likelihood of having co-occurring disorders.

• One high-risk group is people from multi-generational substance abusing families and cultures. In this group, the drug use becomes a seemingly “normal” part of the family culture but leaves many scars.
• People suffering from various types of trauma are also at risk. Trauma can be related to abuse or neglect that has resulted in physical or emotional damage. Other forms of trauma many be related to historical trauma, posttraumatic stress, accidents, diminishing resources, or community-based changes or losses.
• Having a family member with a history of mental illness can increase risk.
• Separation and abandonment from early parenting figures can also contribute to a dual diagnosis.

Most of these factors can be identified by using screening tools or a completeassessmentinterview.

Individuals in these high-risk groups may self–medicate with substances to decrease the intensity of their symptoms of mental illness or effects of life experiences. This form of substance use simultaneously prevents effective treatment of original symptoms and causes problems related to the substance use.

There are different types of co-occurring disorders with varying severity of symptoms. The severity of the different disorders may dictate which disorder should be treated first; severity can be low, moderate, or severe.

Where the dual diagnosis includes two lifelong conditions, treatment for one may impact the other or make treatment for the other more possible. For example, a person who has both ADHD and a second diagnosis like ASD or a learning disability may get more benefit from treatments for the second diagnosis when their lack of focus caused by ADHD is managed through medication. A person with both a learning disorder and a communication disorder may find that addressing the learning disorder is more achievable once barriers to successful communication with providers and teachers are addressed.

Dual diagnoses that have contributing factors like ongoing trauma are likely to improve when the contributing factors are resolved or better managed. Sometimes, as the BHA/P, you may need to help clients brainstorm how to make environmental improvements or handle stressors that contribute to their diagnoses.

Where the dual diagnosis includes substance abuse, with reduced drug and alcohol use or a successful recovery, mental health symptoms may improve or disappear. For instance, depression or delusions that are made worse by alcohol use will improve when the person no longer uses alcohol. However, when a severe mental illness like schizophrenia is primary, the schizophrenia may need to be treated first before the substance disorder can be treated. Regardless of which disorder is the primary, the best treatment for the person is typically an integrated approach. See Chapter E-1: Introduction to Overlapping Issues for more on substance abuse and mental illness.

Because co-occurring disorders are common and often have different treatment needs, it is important to screen individuals early. Initial screenings for co-occurring disorders can be as simple as asking a few questions about a person’s patterns of mood and behavior.

There are many screening tools to help identify individuals experiencing a co-occurring disorder. These tools typically include questions related to symptoms of mental illness and substance abuse. In Alaska, a common screening tool is the Alaska Screening Tool (AST). Other screening tools will be chosen by your THO.

There are many different approaches that have been used to work with people who have co-occurring disorders. Research suggests an integrated treatment approach has the best outcome. Integrated treatment is more than just adding elements of treatment for one diagnosis to elements of treatment for the other. This approach takes all of the client’s needs into consideration. Taking an integrated approach will often mean coordinating with other providers to ensure that the client's treatment needs are being managed and addressed appropriately and comprehensively, speaking more often with your supervisor due to the complexity of the client's needs, and/or supporting medication management.

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

Recovery from co-occurring disorders needs to be looked at from individual, family, and community perspectives:

• Everyone reacts to symptoms uniquely.
• Recovery and success may look very different from one person to the next.
• Family systems that reinforce either negative or positive coping mechanisms will affect recovery.
• Limited access to basic necessities may prevent or discourage people from recovering.
• Community approaches to mental illness, disabilities, substance use, and seeking help will impact clients' comfort levels with following a treatment plan.

Through the Recovery Support Strategic Initiative, SAMHSA has defined four major dimensions that support a life in recovery:

• Health: overcoming or managing one’s diseases or symptoms—for example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has an addiction problem—and, for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing.
• Home: a stable and safe place to live.
• Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society.
• Community: relationships and social networks that provide support, friendship, love, and hope.

Culture and spirituality are also vital to recovery and should be considered in an integrated approach. Cultural considerations may have a serious impact on treatment, and clients' beliefs, traditions, customs, behaviors, history, and experience may all factor into how they understand their disorders. Remember that clients individually define what is culturally relevant to them and their treatment.

Substance Abuse and Mental Health Services Administration (SAMHSA) provides leadership and devotes its resources (programs, policies, information and data, contracts, and grants) toward helping the nation act on the knowledge that 1) Behavioral Health is essential for health, 2) Prevention works, 3) Treatment is effective, and 4) People recover from mental and substance use disorders. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

National Institute on Drug Abuse (NIDA) seeks to lead the nation in bringing the power of science to bear on drug abuse and addiction. This charge has two critical components. The first is the strategic support and conduct of research across a broad range of disciplines. The second is ensuring the rapid and effective dissemination and use of the results of that research to significantly improve prevention, treatment, and policy as it relates to drug abuse and addiction.

Mental Health America (MHA) is a national advocacy organization addressing the full spectrum of mental and substance use conditions and their effects nationwide. MHA’s actions inform, support, and enable mental wellness, facilitate access to quality behavioral health services for all Americans, and emphasize recovery from mental illness. MHA is dedicated to promoting mental health, preventing mental and substance use conditions, and achieving victory over mental illnesses and addictions through advocacy, education, research, and service.