Wed. Oct 20th, 2021

Co-Occurring Disorders Treatment Guide


Someone with substance abuse disorder (drugs or alcohol) and mental illness (depression, PTSD, anxiety, OCD, etc.), the diagnosis is called a co-occurring disorder. Any combination of mental health disorders and substance abuse or addiction qualifies for this diagnosis (sometimes referred to as a dual diagnosis), such as alcoholism and depression, anorexia and cocaine dependence, post-traumatic stress disorder and heroin addiction, prescription drug dependence and anxiety, and more.

Though the symptoms of one disorder may predate the other, both disorders tend to exacerbate one another, making it impossible to extricate the symptoms caused by one disorder from the other. For example, those who attempt to escape symptoms of depression associated with a mood or personality disorder by taking prescription painkillers or shooting heroin will quickly find that though this may be effective the first few times.

In addition to the symptoms of depression, they will soon be struggling with:

  • Cravings for their drug of choice
  • A tolerance to their drug of choice, requiring higher and higher doses
  • Increased episodes of mental health symptoms
  • More intensive or longer-lasting mental health symptoms
  • Experience of withdrawal symptoms
  • Addiction

For the purposes of treatment, it is recommended that clients receive intensive medical and therapeutic intervention and care for both disorders at the same time. This allows them to manage the symptoms caused by the mental health disorder without abusing drugs and alcohol and worsening those symptoms — or allowing an untreated mental health disorder to increase the urge to drink or get high. Comprehensive care that begins during detox and continues through aftercare treatment and support is the best way to build a new life in recovery from co-occurring disorders.

What Comes First: Addiction or Mental Illness?

All people are different when it comes to their experience with addiction and mental illness. Some begin to experience mental health issues during childhood or adolescence and experiment with drugs and alcohol soon after, developing both an addiction problem and a serious mental illness at the same time.

Others may seek out drugs and alcohol in an attempt to “self-medicate” a mental health issue that develops in early adulthood or that develops out of an injury or trauma later in life. Still others may first develop an addiction problem that grows so severe that it causes mental health issues or triggers the onset of symptoms that may otherwise have remained dormant.
What Comes First, Addiciton or Mental Illness


Addiction is defined as both a physical dependence and a psychological dependence upon a drug or multiple drugs, including alcohol. Physical dependence is characterized by a tolerance to the drug of choice (e.g., needing an increasingly larger dose in order to experience the desired effect), and psychological dependence is defined by cravings for the drug or obsessing over getting and staying high.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), substance dependence is a single disorder that is measured on a spectrum from mild to severe and classified according to the substance of choice, with the exclusion of caffeine, which cannot be the subject of a substance abuse/addiction disorder diagnosis. For example, someone struggling with an alcohol problem may be diagnosed with alcohol abuse disorder or alcoholism depending upon the severity.

The diagnostic criteria for almost all substance abuse disorders are the same, according to the DSM-5. There are 11 symptoms that can signify a substance use disorder, and in order to be diagnosed with a mild drug abuse disorder, the person must exhibit two or three of these symptoms.

The National Alliance on Mental Illness (NAMI) reports that the 11 symptoms that characterize a substance use disorder include a pattern of substance abuse that leads to:
  1. An inability to manage obligations at work or at home (e.g., unable to care for children and other dependents, showing
    up late to work or school, repeatedly missing work or school, etc.)
  2. Repeated use of drugs or alcohol in circumstances where it becomes physically dangerous (e.g., driving while under
    the influence)
  3. Ongoing interpersonal issue caused by the effects of chronic drug and alcohol use (e.g., fights with a significant
    other due to behaviors under the influence)
  4. Tolerance for the drug of choice defined by either the need for higher and higher doses in order to feel the desired
    effects of the drug or decreased effects with the same dose
  5. Withdrawal symptoms when without the drug of choice or a substance that is similar in effect
  6. Taking more of the drug than is intended either in a single use session or in a certain period of time
  7. An inability to stop using the substance of choice or to cut down on use
  8. Spending a large amount of time seeking the drug of choice, being high or drunk, or recovering from use of the drug
    or drugs
  9. Avoiding family activities, social events, or former hobbies due to substance use
  10. Continued use of drugs and alcohol despite the realization that the behavior is causing psychological, physical, and/or
    social problems
  11. Cravings for the drug of choice


DSM-5 is the industry standard in the US for identifying the characteristics of any mental health disorder. For each mental health disorder, DSM-5 offers the diagnostic criteria sets, the classification information, and an explanation of the disorder. The diagnostic criteria set includes the symptoms that must be exhibited by the individual and the period of time that those symptoms must be an issue as well as the symptoms and disorders that must be ruled out prior to diagnosing a person with the disorder in question.The specifics of each mental health disorder will be defined by a range of symptoms at different severity levels impacted by the unique experience of the individual. Though everyone lives with a certain level of anxiety, depression, and other common mental health symptoms from time to time, experiencing symptoms that are severe enough to intrude on daily life and relationships for an ongoing period of time often indicates a mental health diagnosis.

Information in the explanation of each disorder will often include:

  • Prevalence of the disorder in the general population
  • Details on how the disorder often develops and the course it generally takes
  • Risk factors for the disorder as well as prognostic factors
  • Measures for diagnosis
  • Diagnostic features of the disorder
  • Other features that are often an issue as well that also support a diagnosis of the disorder
  • Diagnostic features of the disorder that are impacted by or related to cultural or gender issues
  • How the disorder impacts the person’s ability to function

Why Is Underlying Mental Illness the Root Cause of Addiction?

In some cases, a mental health disorder predates the development of a drug or alcohol abuse disorder; in other cases, addiction becomes an issue first and mental health symptoms are not apparent until later — sometimes, they are triggered or worsened by drug use.

Everyone is different and there is no one cause of addiction, though living with a mental health disorder may increase the likelihood of developing an addiction disorder — and vice versa.

In most cases, a combination of issues may contribute to the development of addiction and/or mental health disorders, including:

  • Biology:Some people are just wired so they are deeply attracted to the high created by drug and alcohol use. This may be due to prenatal development, early childhood exposures, accident, injury, or any number of possible things that could change the chemical makeup and function of the brain even slightly.
  • Genetics:Having a close relative who struggles with drug or alcohol addiction may increase the likelihood of developing a substance abuse problem. Similarly, having a close relative with a mental health disorder may mean an increased chance of developing the same, or a similar, mental health issue.
  • Trauma:Sexual abuse, physical abuse, natural disaster, and wartime experiences — exposure to trauma and near-death experiences can contribute to the urge to use drugs and alcohol as a coping mechanism as well as the experience of significant mental health issues, such as depression, post-traumatic stress disorder, anxiety, and more.
  • Environment:Growing up or living in a home or other environment that is permissive of heavy drug use may contribute to the development of a substance abuse disorder
  • Life Experience:Use of certain drugs and alcohol in high amounts as well as other significant life experiences, like developing a chronic illness, may contribute to the development of mental health symptoms.




Integrated treatment is a comprehensive rehabilitation program that offers all the medical, therapeutic, and holistic resources necessary to help clients heal physically, mentally, emotionally, and spiritually. No matter what the mental health diagnosis, but especially if co-occurring disorders are the issue, integrated care is recommended.

Why Integrated Treatment Is Recommended

Living with both a mental health disorder and substance abuse or addiction is a deadly combination. The poor lifestyle choices associated with these two disorders often translate into early and/or sudden death for the individual if no treatment is received.

Some common life-threatening issues that co-occur with a mental health disorder include:

  • Heart disease
  • Diabetes
  • Smoking
  • Asthma
  • Obesity

Thus, addressing all disorders that contribute to the lifestyle choices that may hasten an early death is imperative for those who are living with co-occurring disorders. Integrative treatment offers a range of treatment services to the individual, providing the person with everything necessary to heal on all levels. Specific services will vary depending upon the needs of the client but may include resources to assist in lifestyle changes in addition to directed addiction and mental health treatment.

Recommended lifestyle changes that promote health and wellness at an integrated treatment program may include:

  • Improving sleep habits
  • Addressing any chronic medical conditions
  • Improving communication skills
  • Improving nutritional and eating behaviors
  • Working on family relationships
  • Addressing job skills and work-related issues
  • Managing legal issues

In this way, clients receive everything they need to get back on track, return to work, rebuild relationships at home, and build a strong support network in recovery.


Each client should have a unique treatment plan, but for those who are living with both a substance abuse or addiction disorder and a mental health disorder, an integrated treatment plan may typically include the option of:

  • Medical detox:For many who struggle with addiction to drugs or alcohol, the detox period, or first days and weeks after the cessation of substance use, can be defined by physical and mental withdrawal symptoms. Detox services provide clients with medical support and monitoring if needed to help them stabilize in treatment.
  • Evaluation:To ensure that all current mental health symptoms are accurately diagnosed, an evaluation is the next step in integrated treatment. Additionally, all other issues that may be an obstacle in the client’s path to recovery are identified.
  • Diagnosis:Based upon the evaluation results and the reported experience of the client, diagnoses are made to help the client better understand and frame past experiences and plan for the future.
  • Treatment plan:A unique treatment plan is created for each client that integrates a range of therapeutic and medical interventions with the goal of empowering the client to heal from addiction, learn how to manage mental health symptoms, and address any personal issues that may be problematic.
  • Personal therapy:One-on-one therapy is the foundation of recovery, providing the client with a safe and confidential forum to discuss past experience, current issues, changes that occur in therapy, and goals for the future. As treatment goals are reached based on the initial treatment plan, the client can work together with the therapist to create new therapy goals and adjust the treatment plan accordingly.
  • Group therapy:There are different types of groups that may be a part of an integrated treatment program: 12-Step groups, groups that focus on a specific aspect of addiction, a support group for people who share the same mental health issues, groups that help participants deal with a commonly shared life issue (e.g., parenting, legal problems, job seeking, etc.).
  • Family therapy:Working together with loved ones to rebuild relationships damaged during active addiction and untreated mental health symptoms can play a significant role in recovery, especially if the client will be returning home to live with family members after treatment. Empowering family members to connect with treatment that will allow them to heal in their own ways while also working to help all members to learn positive communication skills.
  • Aftercare plan:Before leaving treatment, clients are encouraged to work with a therapist to create a unique aftercare plan. Much like the treatment plan, this should include a unique combination of treatment services that will serve the treatment goals and needs of the client on an outpatient basis during and after the transition into independent living in recovery.
  • Aftercare services & support:Clients who seek integrated treatment for co-occurring disorders are encouraged to create an integrated aftercare plan that incorporates services that address treatment needs on an ongoing basis. Continued mental health care is recommended as is support building in recovery from addiction and personal therapy as well as whatever holistic and alternative therapies were working for the client during treatment.


There is no mental health disorder that cannot be effectively impacted by integrated treatment. According to
Medline Plus, some of the mental illnesses that will benefit from comprehensive medical and therapeutic care include:

  • Depression
  • Schizophrenia
  • Bipolar Disorder
  • Anxiety Disorders
  • Obsessive-Compulsive Disorder
  • Post-Traumatic Stress Disorder
  • Personality Disorders
  • Attention Deficit Hyperactivity Disorder
  • Eating Disorders

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