Dual Diagnosis: Substance Use and Co-Occurring Mental Disorders

Introduction

The abuse of substances and dependence on them are considered to be two separate types of disorders, according to the DSM-V. The DSM-V is a manual used by professionals in the fields of medicine and mental health, specifically for diagnosing disorders related to a patient's mental health and substance use. Through this manual, there is a standardized way of diagnosing such disorders (Rockville, 2005). Substance use disorders are often found to co-exist with other disorders. This paper highlights the assessment and treatment of substance-related disorders and their co-morbid conditions.

Co-Occurring Mental Disorders and Substance Use

The DSM-V progresses from the DSM-IV in that it places disorders on a spectrum, replacing the separate diagnostic categories that were previously used. This spectrum moves from mild to acute presentations. The DSM-V further classifies the use of specific substances into distinct disorders, with the exclusion of caffeine. Other changes include the requirement that at least two symptoms be identified for a disorder to be diagnosed as mild — drawn from a list of 11 symptoms provided by the DSM-V. This differs from the DSM-IV, which required just one symptom for a mild disorder diagnosis. The DSM-V has also added drug craving as a symptom while removing criteria that do not apply globally, such as negative encounters with law enforcement (American Psychiatric Association, 2013).

Professionals working with substance abuse patients must be aware of the co-occurrence of mental disorders and substance use disorders, as well as conditions that present similar symptoms — such as withdrawal or intoxication. This awareness is intended to help counselors become more familiar with the terminology surrounding mental disorders and to better assist patients who exhibit these symptoms (Rockville, 2015).

Counselors who deal with addiction are most likely to encounter personality disorders, as is typical in quadrant III substance abuse treatment settings. People with personality disorders exhibit traits that persist long-term, leading to social and occupational dysfunction. Symptoms manifest through their thoughts, emotions, interpersonal interactions, and impulse control. Counselors can observe these symptoms by noting the patient's perception of the world, how they think about themselves and others, the intensity of their emotions, how they respond to specific situations, and the nature of their relationships (Rockville, 2005). Flynn et al. (1997) note a high co-occurrence of substance abuse and antisocial personality disorder, and treatment for substance abuse has been more frequently directed toward those suffering from this disorder.

Psychotic disorders are characterized primarily by problems with cognition. These include hallucinations and delusions. Delusions affect a person's thoughts based on false premises and can hinder their functionality — for example, a person may believe they are in danger from others or mistake their own identity. In hallucinations, a person may perceive things that do not exist: seeing, hearing, smelling, or feeling stimuli that are not present. Psychotic disorders are more prevalent in mental health settings, and when combined with substance abuse, the abuse tends to reach severe levels. This population represents the most severely and persistently mentally ill. Gustafson (1999) notes that this population has increasingly been seen in substance abuse treatment programs. Substances such as cocaine can induce delusions and hallucinations beyond simple drug toxicity, and a psychotic person may exhibit these symptoms following intoxication (Rockville, 2005).

Some symptoms of mood disorder include an inability to properly express emotions, or the expression of emotions that are inappropriate or excessive. While it is normal for individuals to experience emotional highs and lows, a person with a mood disorder experiences these states at levels well beyond the norm. Mood disorder may co-occur with a substance abuse disorder and may even influence the type of substance used. Depression, mania, and bipolar disorder are among the common presentations of mood disorder (Rockville, 2005).