Dual Diagnosis: The Importance of Simultaneous Treatment

woman-sitting-on-rockEditor’s Note: Kim Dennis, MD, CEDS is the CEO and medical director for Timberline Knolls, a residential treatment center that specializes in the treatment of addictions, eating disorders, posttraumatic stress, and co-occurring conditions. Her continuing education presentation for GoodTherapy.org, titled Co-Occurring Problems: When Disordered Eating and Substance Use Collide, is scheduled for 9 a.m. PDT on April 17, 2015. This event is available at no additional cost to GoodTherapy.org members and is good for two CE credits. For details, or to register, please click here.

Today, in the world of behavioral health, a dual diagnosis—the co-occurrence of a substance abuse problem with a mental health condition—tends to be the rule, rather than the exception. It is rare, indeed, to have a person enter a treatment program with a single diagnosis.

Eating disorders, for example, commonly co-occur with substance abuse. Up to 35% of alcohol or illicit drug abusers have eating disorders compared to only 3% of the general population. Similarly, up to 50% of those with eating disorders have a concurrent problem with alcohol or drug abuse. We know that one underpinning of most addictions and mental health problems is the inability to effectively cope with emotional pain. A person may move from one addiction to another condition, and back. In other words, at any given time, the person uses not only what is available, but what is “working.”

Dual diagnoses are in no way confined to issues relating to food or drugs, though. Substance abuse also often co-occurs with an emotional/psychiatric concern. According to a report published by the Journal of the American Medical Association, 37% of alcohol abusers and 53% of drug abusers also have at least one serious mental health condition. Of all people diagnosed as mentally ill, 29% abuse either alcohol or drugs.

Kim Dennis, PhD

Kim Dennis, PhD

For many years, the standard of care was to treat co-occurring disorders sequentially or in parallel, rather than with an integrated approach. An individual might have received counseling for an issue with alcohol; then, once he or she was in recovery and strongly committed to sobriety, that person might start seeing another therapist for an eating disorder. This was standard operating procedure simply because few professionals possessed expertise in two specialty areas. For myriad reasons, this sequential approach often led to poor outcomes.

Unfortunately, many programs still adhere to this approach. This treatment often proves inadequate and incomplete—a person may get off of heroin, for example, only to become more addicted to food, especially sugar, to deal with residual drug cravings. Or anorexia may be alleviated while depression escalates, due to lack of attention to the co-occurring mood disorder.

Research supports that concurrent treatment offers the best outcomes for populations experiencing many different combinations of co-occurring issues. Through holistic treatment, all aspects of the individual are treated—mind, body, soul, and spirit. For instance, a treatment approach that is rooted in the guiding principles of 12-step recovery in conjunction with the tools inherent to dialectical behavior therapy (DBT) can treat a whole array of mental health issues and co-occurring disorders.

For example, in the case of an individual struggling with an eating disorder and a substance use problem, both issues are treated as primary, potentially fatal concerns with emotional, spiritual, physical, cognitive, and social manifestations. Trauma history is quite often an underlying thread among people with mood disorders, anxiety issues, eating disorders, and addictions. Both illnesses and their common underlying causes are targeted and treated.

Considering the current data and trends, treatment-seeking populations rarely ever have only a single diagnosis. Therefore, those in the behavioral health field, and those soon to enter, must prepare themselves to be cross-trained to effectively help people in treatment reach life-long and lasting recovery from the entire constellation of symptoms those people face.

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  • Francine

    Francine

    March 23rd, 2015 at 8:24 AM

    So critical to understand that often there is no help for one ailment without also addressing the others that go along with that.

  • Ron

    Ron

    March 23rd, 2015 at 10:29 AM

    I suppose that my personal thoughts on this are that the doctor will be treating the patient and not just the symptoms so when they effectively do this then they are hitting all of the issues on the head, and not just the one or two that could be mentioned.

  • Russ

    Russ

    March 23rd, 2015 at 3:54 PM

    I would love to know how one determines which is the one that should be addressed first or if this is something that has to truly be addressed all at the same time. My other question is in regards to kn wing which came first, what caused what, and then how do you treat that. It would seem to me that it would be important to know where everything is stemming from/

  • Teel

    Teel

    March 24th, 2015 at 3:37 AM

    would you say that most of the time one diagnosis causes another or is this person just so unfortunate to have multiple mental health issues going on all at the same time?

  • Athena

    Athena

    March 24th, 2015 at 5:36 AM

    Once a person was diagnosed with a certain ailment, it’s often accompanied with another co-occurring disorder. And it would be a big help to know which one should be treated first. Should it be treated one after the other or all at the same time as @Russ has stated?

  • Dr. Kim Dennis

    Dr. Kim Dennis

    March 24th, 2015 at 1:36 PM

    Ron,
    Yes, ideally the doctor is treating the patient holistically. Sadly, many doctors treat the diagnosis they are most familiar and comfortable with. Sometimes, unfortunately, co-occurring disorders go unrecognized, minimized and/or untreated.

  • Dr. Kim Dennis

    Dr. Kim Dennis

    March 24th, 2015 at 1:37 PM

    Sometimes one has a clear onset before the other. Many times the picture is unclear and both emerge concomitantly. In either case, having both makes each more difficult to treat.

  • Dr. Kim Dennis

    Dr. Kim Dennis

    March 25th, 2015 at 9:26 AM

    Russ,yes, it is critical to explore where all symptoms (the entire disease package)stem from. Almost always that leads back in some way, shape or form to trauma for people with multiple co-occurring disorders. We address all disorders at once, however, many times clients are willing to work on only one or a few areas at a time. We meet people where they are because they need to have a sense of safety in order to recover (especially when trauma is involved). Typically with the patient, we work to prioritize treatment goals from life interfering/potentially deadly symptoms, to therapy interfering, to eventually quality of life interfering symptoms. Forced treatments, or shame based/punitive treatments don’t work with this patient population.

  • Ron

    Ron

    March 25th, 2015 at 11:33 AM

    It’s sad that there are still those providers who will automatically fall back only on what they know without fully understanding and treating whatever the meat of the problem actually is.

  • kimmie

    kimmie

    March 28th, 2015 at 7:25 AM

    one more tragedy will come when no one even knows the different issues that they are facing and may not ever learn the full truth because one is being masked by another

  • Paula

    Paula

    March 30th, 2015 at 3:56 PM

    So I am guessing that for most with a dual diagnosis like addiction and depression, the underlying thought is that there may have never been an addiction issue had there not already been another prior mental health disorder to set it all in motion? My thoughts would be that one begets the next and then as a coping mechanism you may then pick up another behavior that is reckless trying to mask the others.

  • Dr. Kim Dennis

    Dr. Kim Dennis

    March 31st, 2015 at 2:47 PM

    Typically that is how we think of it.However, someone’s drinking may also trigger an underlying genetic predisposition towards depression into a full blown major depressive disorder. Exposure to ongoing doses of alcohol, as a depressant, would represent an environmental trigger to bring the genetic predisposition to depression to life in this case. Also possible is someone with a predisposition to both alcoholism and depression, and an environmental trigger (or several), like loss or trauma, causes both to manifest. Regardless, both must be addressed and treated in order to help those who suffer achieve sustainable recovery. And further, the underlying causes must be addressed or else relapse and/or another addictive disorder will ensue. For example, it is not uncommon for those who have alcoholism to get “sober” and then use sex addiction, work addiction or compulsive eating to manage their untreated depression and trauma.

  • Dual Diagnosis Helpline

    Dual Diagnosis Helpline

    October 24th, 2016 at 3:16 AM

    Nice post! Simultaneously treatment for both mental health Illness and substance abuse is necessary. Because if you treat mental illness but not working on substance abuse treatment then other treatment go waste.

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