¶ Understanding Co-Occurring Disorders
Welcome back to another episode of our licensure exam podcast . I'm Dr Linton Hutchinson and I'm here with my co-host , Stacey Frost . This episode , part of our demystifying disorders series , is all about co-occurring disorders , also called dual diagnoses , which is a topic that you'll need to know for the exam .
We'll be looking at the signs and symptoms for co-occurring disorders , as well as the screening and assessment process . So , Stacey , why don't you start us off with the basics ? What the heck is a co-occurring disorder ?
So , linton , this is when your client has both a substance use disorder and a mental health disorder .
Now , if your client has a substance use disorder , it's very possible that they also have an anxiety disorder , post-traumatic stress disorder , a depressive disorder , bipolar , a personality disorder , borderline and antisocial , for example , have a really high comorbidity with substance abuse . They could also have an eating disorder or a psychotic disorder like schizophrenia .
So you need to be familiar with the symptoms of these disorders so that you can determine which intervention strategies will be most effective for your client in their recovery process .
Yes , especially for the exam . So what combinations are therapists most likely to encounter in practice and on the exam ?
Okay , so one of the most common pairings that you see is bipolar one and alcohol use or stimulant use . So a client with bipolar might use alcohol to cope with depressive episodes or use stimulants to prolong their manic or those really high energy phases .
Mm-hmm , and there's also a strong link between PTSD and alcohol addiction . The numbing effects of alcohol provide temporary relief from PTSD symptoms like flashbacks and hypervigilance , but the alcohol use ultimately makes the PTSD worse .
For your exam , if your client is given a provisional diagnosis of PTSD , you should also be on the outlook for a possible co-occurring disorder . Mm-hmm .
And there's also another common combination that you might see is major depressive disorder and opioid use disorder .
So you could have a client who started off by using prescription opioids to manage a pain condition and then , after long-term , use their brain chemistry , mainly those feel-good neurotransmitters , dopamine and serotonin well , they get off balance , kind of out of whack and now they're dealing with depression too .
Or you might have a client who starts off using heroin to self-medicate their depressive symptoms and their emotional pain Wow . But eventually this heroin use spirals into full-blown addiction and ultimately deepens their depression .
Got it Now , the age-old question which came first , the chicken or the egg ?
I know , you were going to say that .
Oh , with you having chickens , what else could I say ?
I appreciate a good chicken joke . Thank you , Linda Okay .
So seriously ? Which came first , the addiction or the mental illness ?
Well , just like which came first , the chicken or the egg , this is different for everyone . So some clients might have started off to experience symptoms of a mental illness when they were young , and maybe around that time they also started to experiment with drugs and developed an addiction .
Right .
Others might have tried to self-medicate and cope with a pre-existing mental illness by using drugs , and there are still some other clients who may have developed the addiction first and this acted kind of like a trigger for a mental illness like depression , anxiety or a psychotic disorder .
Okay , Now let's shift over into talking about some of the signs and symptoms that a client may be experiencing with a dual diagnosis . What are some of the red flags to look out for in the case study or subsequent sessions with the client Stacey ?
Okay . So we've got things like rapid mood swings . This could indicate a mental health issue like bipolar disorder , combined with substance use intended to self-medicate Mm-hmm , you could . If you see something like social withdrawal and isolation , this can happen with depression , anxiety or other disorders and really be exacerbated by drug or alcohol use .
Then we've got difficulty concentrating or remembering things . So cognitive issues might signal psychiatric problems that are being compounded by substance use . Those are off the top of my head . Any other signs you'd like to add , Linton ?
Well , you've covered some of the big ones , but a few other signs that could suggest a dual diagnosis are repeated risky or dangerous behaviors . Being impulsive and poor judgment linked to mental illness can also be magnified by substance intoxication . Paranoia or hallucinations , symptoms of schizophrenia or other psychotic disorders may become worse with heavy substance use .
Also , if your client exhibits poor self-care and hygiene or experiences dramatic changes in sleep patterns . That's a key , mm Gotcha . Thanks .
Linton , can you talk a little bit more about the screening process for co-occurring disorders ?
The components of the screening process depend on the treatment setting . Really , if you're working in a mental health settings , you'll want to one screen for past and present substance abuse . If there's any recent or current substance abuse , you'll also want to determine any safety risk associated with intoxication and withdrawal .
If you're in a substance use treatment setting , then you'll be screening for safety risk associated with suicide , violence , ability to care for self , hiv , hepatitis and other risky behaviors , past and current mental health problems , cognitive and learning problems and any other dangers and trauma . That's good , that makes sense .
Okay , and once you've determined that your client likely has a co-occurring situation , so they've got that substance use issue combined with a mental health issue , then you're going to continue with a very detailed assessment to determine the exact nature of your client's problem so you can come up with treatment recommendations .
So you're going to ask your client questions about their background , including family , community and other issues . So you're going to ask your client questions about their background , including family , cultural , gender , sexual orientation issues , trauma , marital status , legal financial health , education , housing status , strengths and resources and employment .
Well , you're also going to ask your client questions about substance use , including the age of their first use , primary drugs they've used , any patterns of use and past or current treatment .
You'll ask about psychiatric problems , including family and client history of psychiatric issues , current diagnoses or symptoms , medication and whether they are adhering to their medication and past successful treatment for mental disorders .
And you'll conduct an integrated assessment , which means you're looking at the relationship between the mental disorder or disorders and the client's substance use .
So basically everything in the kitchen sink .
You got it , yep .
Okay On your exam .
If you suspect that your client may have a co-occurring disorder , here are some assessment tools you might consider using to evaluate their situation further the structured clinical interview for the DSM disorders , or the SCID , which is a semi-structured interview guide used by clinicians and researchers to determine the presence of a DSM-5-TR diagnosis for mental health
disorders . Different versions screen for mood disorders , substance use , anxiety and psychiatric disorders . Here's another the mini-international neuropsychiatric interview . Say that twice , stacy .
That's a mouthful Linton Boy . We'll just call it the mini for short .
Really Okay , mini , which is a short , structured diagnostic interview that screens for mental health disorders commonly associated with substance use , disorders , including mood , anxiety , psychotic and eating disorders and , of course , one of your favorite , a biosocial assessment . This takes a comprehensive history , look at biological , psychological and social factors .
This allows the clinician to assess for signs of multiple conditions rather than taking a more narrow focus . The interactive effects of disorders are considered , for example , depression symptoms exacerbated by alcohol abuse or psychosis aggravating PTSD . This helps determine primary versus secondary illnesses .
Good ones . And of course there is the mental status examination , which is a structured way of observing and describing a client's psychological functioning at any given point in time .
So when you observe the client's appearance , behavior , speech , thought process , cognition , insight and judgment , this is going to allow you as a clinician to pick up on signs and symptoms of multiple conditions that might be present . So the MSC also helps differentiate symptoms that could be attributed to different disorders .
For example , disorganized speech could indicate psychosis , mania or possibly a side effect of substances . So it gives you kind of a platform to explore more things in depth once you've identified kind of an umbrella of symptoms .
That makes sense . Yeah , and all right . So this brings us to the end of this episode . How about giving us a quick summary before we sign off ? Stacey , Sure .
¶ Understanding Co-Occurring Disorders
Co-occurring disorders , also called dual diagnoses , is when a person has both a substance use disorder and a mental health disorder . Some common combinations include bipolar one disorder and alcohol use or stimulant use , ptsd and alcohol and depression and opioid use .
Signs of co-occurring disorders can include mood swings , withdrawal , cognitive issues , risky behaviors , paranoia and hallucinations and poor self care , and there are a variety of assessment tools that can be used to screen for and comprehensively assess co-occurring disorders , including the structured clinical interview for DSM disorders and the mini international neuropsychiatric
interview .
Thanks , stacey , and until we meet again . Remember it's in there .