Many people who seek help for their recovery from alcohol dependence may also have received a diagnosis for another mental health condition which runs alongside their alcohol misuse problem, this is known as Dual Diagnosis.
People who have received a dual diagnosis are particularly vulnerable and their treatment needs to be managed carefully as they tend to have poorer outcomes, both in terms of their ability to control their drinking, and in seeing improvements in their mental health than people with just one condition. (1)
People with a severe mental illness are far more likely to being diagnosed with a substance misuse disorder that someone without any form of mental illness.
Dual diagnosis patients also have a higher rate of relapse than individuals who have a problem with alcohol but who do not have a coexisting mental health condition (14)
People with a dual diagnosis tend to find it difficult to adhere to their medication advice and are more at risk of hospitalization, homelessness, suicide and are more disruptive and violent than those with a single disorder. (5,14)
One important point apparent with this population is that they have a greater sensitivity to alcohol than people without a co-occurring, mental illness.
They are more likely to be affected by drinking a lesser amount, and drinking alcohol does tend to make their mental health condition worse.
There is a fear that a psychiatric disorder can go undetected due to the overbearing nature of the alcohol symptoms, therefore its possible to miss the symptoms of mental illness as they can be attributed to alcohol-related behaviour.
The challenge for health professionals when dealing with dual diagnosis is whether to treat one of the conditions first before moving on to the other one, having both treatments run parallel with each other or integrating them so one service works on the two conditions together.
The integrated approach avoids any confusion and communication problems that tend to occur when different sets of practitioners are responsible for delivering each separate treatment plan. (5,6)
It is a very complicated clinical group to treat as it is difficult to establish whether poor mental health led to the alcohol problems or vice versa, or whether there are separate factors responsible for each.
There is a lot to untangle and its important to fully understand how both conditions interact with each other as it has implications for their treatment programmes. (6,10)
It has been suggested that a lot of the difficulties treating dual diagnosis patients relate to the fact that the mental health and substance misuse practitioners although very skilled in working with patients in their own area do not have sufficient expertise or understanding about the other condition.
This often tended to negatively impacted on the person with a dual diagnosis and so limited their chances of a favourable outcome. (10, 14)
The mental health disorders that frequently co-occur with people with alcohol problems are Mood Disorders, Personality Disorders, Schizophrenia and trauma elated conditions such as Post Traumatic Stress Disorder (PTSD).
Below, we discuss some of the mental health conditions that are frequently diagnosed alongside alcohol dependency:
This has been found to be related to more severe alcohol use and more binge drinking which therefore tends to have more serious legal and physical consequences.
It has been suggested that this condition develops in response to adverse experiences early on in their lives and because of a disruption to the course of a person’s emotional development. (13,16)
There are many challenges faced when treating people with this combination of disorders, this is because the complicated and disrupted nature of their symptoms interfere with the course of their treatment.
If someone has been diagnosed with a personality disorder they may tend to display characteristics such as being unable to manage and contain the intense feelings they are experiencing.
Because they are unable to manage their emotions they are likely to turn to alcohol or other substances to help soothe themselves. (13,16)
They also find it difficult to sustain meaningful close relationships and because of this they can begin to feel lonely and alienated from others, because of this they tend to avoid people which only reinforces the condition.
There has been a strong association between high levels of alcohol consumption and anti-social personality disorder, research has indicated that over 80% of people with the condition have severe substance misuse problems as well, particularly if they have been diagnosed with another mental health condition as well. (13,16)
It has been widely acknowledged that traumatic experiences play a significant role in the development of substance misuse problems. (14,15)
PTSD is an extremely distressing condition in which a person who has experienced a traumatic event is plagued by persistent and intrusive thoughts and memories relating to the event via flashbacks and the frequent recall of visual images relating to the event.
There are also unpleasant accompanying emotional feeling experienced as well such as anxiety, fear and guilt as images of the event automatically intrude into a person’s consciousness.(4)
Initially PTSD was thought to be mainly experienced by soldiers who had fought in wars but the area has received a lot of attention over the last 20 years and it has been found people who have experienced abuse, natural disasters, severe illness and serious accidents have also developed PTSD symptoms, particularly if they felt a serious and imminent threat to their life at the time. (14, 15)
PTSD is one of the most common disorders that co-exists with alcoholism as alcohol is a strategy people with the condition tend to use to numb unpleasant emotions. The symptoms of PTSD have been know to be strong drivers of alcohol misuse. (14)
Mood disorders are characterised by symptoms which include having a depressed mood for most of the day as indicated by feelings of sadness and emptiness, a lack of interest in any activities, agitation, fatigue, feeling worthless and an inability to think or concentrate. (1,11)
The two main Mood Disorders are Depression and Bipolar disorder. People diagnosed with bipolar disorder tend to fluctuate between depressive states and mania where they exhibit an elevated and positive mood for a period of time where their self-esteem is much higher, they engage in more pleasurable activities and they are able to focus on specific tasks. (11)
People diagnosed with mood disorder and alcohol problems are more prone to homelessness, unemployment and poor relationships and also at increased risk of self-harm due to the fact that alcohol depletes their ability to inhibit impulsive behaviour. (10)
There is a particularly strong association between alcohol and mood disorders. There is an increased risk of suicide and self-harm with those who suffer from alcohol dependency and also have depression as high alcohol intake does exacerbate depressive states. (1,11)
There is a tendency for people with a mood disorder to use alcohol as a sedative and to self-medicate to alleviate their symptoms but when, combined with medication it can lead to them becoming intoxicated far more quickly. The combination of anti-depressants and alcohol can lead to gastric and liver disease. (1)
Schizophrenia is a debilitating long-term condition and people diagnosed with it experience various distressing psychological symptoms.
It can take a long time to diagnose due to the varied, complex nature of its symptoms.
Typical symptoms however tend to include problems with perception such as seeing things that are not real (hallucinations), delusional thinking based on distorted beliefs, muddled thinking and a tendency to lose interest in their daily activities and to neglect their personal hygiene. (8,11)
They tend to be vulnerable to psychosis, meaning that they lose touch with reality and aren’t able to separate their own thoughts and feelings from reality.
They also withdraw socially and tend to avoid seeing their friends and can struggle with language (for example disorganised or incoherent speech). (8,11)
Research has indicated that genetic factors play a role in a person with a dual diagnosis of Schizophrenia and alcohol problems and those who have a family history of alcohol problems are also at risk.
The Self-medication hypothesis has also been used to explain why people with Schizophrenia are vulnerable to alcohol problems as alcohol is consumed to increase happiness levels, decrease the negative effects associated with feeling depressed and to reduce social anxiety and tension. (10)
Treating people with a dual diagnosis with only alcohol interventions without any contribution from the area of psychiatry has not tended to be effective, so it’s imperative to devise treatment plans that take both diagnosis into account as it has also been claimed that failure to treat the psychiatric diagnosis tends to have poor outcomes for the alcohol disorder as well. (10,14)
It is clear that effective treatment plans for dual diagnosis patients should take an integrated approach rather than a tendency to focus on each of the conditions separately one after the other, or run parallel to each other simultaneously. (3)
It is imperative for the healthcare professionals working with dual diagnosis patients to fully understand both the mental health condition that the client presents as well as the alcohol dependence, and how the two conditions tend to interact with each other.
That’s why Integrated treatment is seen as the ideal scenario as this avoids the contradictory messages that patients sometimes receive from separate services who treat them, as there tends to be little or no communication between them due to a lack of understanding each service has of the other condition. (3,14)
It is essential to take an individual approach when working with dual diagnosis patients. This is because even if two people are both heavy drinkers and been diagnosed with depression its important to appreciate that their depressive symptoms may differ due to the diagnostic process.
For example two people can be diagnosed with depression but display different symptoms. So a blanket approach is not at all sufficient for dual diagnosis patients.
It has been found that dual diagnosis patients will go through various stages in their quest for recovery and it is important for healthcare professionals to understand which stage each person is in and then devise appropriate interventions that are compatible with that particular stage.
There have been 4 stages identified on the path to recovery for dual diagnosis patients, these are Engagement, Persuasion, Active Treatment and Relapse Prevention. It can have negative consequences for someone if they receive an intervention that they are not ready for at that time. (3,14)
There are a wide range of treatment options available for people who have received a dual diagnosis which can be included on their individual treatment plan, these options include:
Due to the fact that they have been diagnosed with a mental health condition and alcohol dependency then patients may require specific medication to help target their psychiatric symptoms to make sure they are not overwhelmed by their symptoms.
This will put them in stronger position to work on their excessive alcohol use.
Pharmacology for example is key in reducing symptoms of PTSD as this enable people to erect a greater distance between the distressing event and themselves and start to find their feet to tackle the alcohol problem.
If they have become physically dependent on alcohol and they are experiencing withdrawal symptoms then it will be necessary to be placed on a detox programme to reduce the unpleasant symptoms that they are experiencing. (12)
Motivational interventions have been found to be effective in helping dual diagnosis patients find the reasons to understand and accept their behaviour and to find the desire to change.
Trained therapists showing empathy and understanding work with the patients to guide them through the stages of change and discuss the range of options open to them. (9,14)
This process takes time and even though resistance is expected the strong relationship that develops between therapist and patient will enable the client to find what they need to enhance their recovery.
It is important for the therapist to understand the stage of change and level of motivation the client is at when working with them. (9,14).
People with a dual diagnosis are very susceptible to interpersonal stress and being confronted so a patient and understanding approach is essential. (3,6)
MI has been particularly valuable in helping people with a dual diagnosis gain insight into how alcohol has affected their lives. (6)
It is likely long term therapy will also be required to target any psychological issues the patient needs to overcome in order to move forward.
The patient may have gone through traumatic experiences in childhood or as an adult so specific psychological therapies may be required to help them deal with those experiences.
DBT is another form of therapy that has been found to be effective in helping people who have a dual diagnosis of alcohol dependence and a personality disorder. This form of therapy helps individuals who find it difficult to regulate their emotions.
A DBT therapist will work with the client to improve their ability to manage their emotions more effectively by helping them to change the nature of their response when confronted with strong emotions.
The concept of mindfulness is an important tool in DBT as people learn new skills to manage the thoughts that tend to lead to negative emotions. (7)
It has been recommend that a treatment plan for Dual Diagnosis patients address the person as a whole to see how their separate conditions overlap and interact each other.
Professionals developing treatment programs tend look at other aspects of their life as well as these can all contribute to their chances of a successful recovery. (3,6)
Other components to their treatment plan include an assessment of their housing needs, what job or career they would like to follow, or whether they want to go to college or university to study.
It’s also important to consider the social side of their life such as relationships (family or friends) and their place in the community including activities and hobbies. (3,14)
It is so important for health care professionals planning treatment to fully understand the unique nature of the substance misuse and co-occurring mental health condition as different combinations of the two need to be treated in a specific way.
For example, it is recommended that alleviating the distressing symptoms of PTSD first put the patient in a better place to begin any psychotherapy sessions to help with the alcohol problems.
Depending on the individual nature of their situation and the way the two conditions interplay with each other family therapy and 12 step programs may also be utilised in their treatment plan
(1) Attenborough, J. (2010) Alcohol and Mood Disorders in in Phillips, P., McKeown, O., & Sandford, T. (ed) Dual Diagnosis: Practice in Context. John Wiley & Sons. Chichester
(2) Bennett, P. (2003) Behavioural and Cognitive Behavioural Approaches to Substance Misuse Treatment in Peterson, T. & McBride, A. (ed) Working with Substance Misusers: A Guide to Theory and Practice London. Routledge.
(3) Champney-Smith, J. (2003) Dual Diagnosis in Peterson, T. & McBride, A. (ed) Working with Substance Misusers: A Guide to Theory and Practice London. Routledge.
(4) Conway, M.A., Holmes, E.A. (2005) Autobiographical Memory and the Working Self in Braidsby, N. & Gellatly. A. (ed) Cognitive Psychology. Oxford University Press. Oxford
(5) Gossop, J. (2005) Multiple Substance Misuse and Multiple Dependencies in (ed) Dual Diagnosis and Psychiatric Treatment: Substance Misuse and Cormorbid Disorders. Marcel Dekker. New York
(6) Mueser, K.T., Kavanagh, D. (2004) Treating Comorbidity of Alcohol Problems and Psychiatric Disorder in Heather, N., & Stockwell, T. (ed). The Essential Handbook of Treatment and Prevention of Alcohol Problems. John Wiley & Sons. Chichester
(7) Northamptonshire Healthcare NHS Foundation Trust (2021) Dialectical Behavioural Therapy
available@ download.cfm (nhft.nhs.uk)
(8) NHS (2021) Schizophrenia: An Overview available @ Overview – Schizophrenia – NHS (www.nhs.uk)
(9) Peterson, T. & Davies, M. (2003) Motivationally Based Interventions for Behaviour Change in Peterson, T. & McBride, A. (ed) Working with Substance Misusers: A Guide to Theory and Practice London. Routledge.
(10) Phillips, P., Johnson, S. (2010) Explanatory Models for Dual Diagnosis in Phillips, P., McKeown, O., & Sandford, T. (ed) Dual Diagnosis: Practice in Context. John Wiley & Sons. Chichester
(11) Pratt, C.W., Gill, K.J., Barrett, N.M., Roberts, M.M. (2007) Psychiatric Rehabilitation. Elsevier Academic Press. London
(12) Raistrick, D. (2004) Alcohol Withdrawal and Detoxification in Heather, N., & Stockwell, T. (ed) The Essential Handbook of Treatment and Prevention of Alcohol Problems by (2004). John Wiley & Sons. Chichester
(13) Tavistock & Portman NHS Foundation Trust (2021) Personality Disorders
(14) Tsanos, A. (2014) Concurrent Disorders in Herie, A. & Skinner, W. (ed) Fundamentals of Addiction: A Practical Guide for Counsellors. CAMH. Canada
(15) Van de Kock (2014) The Body Keeps the Score. Viking Press. New York
(16) Verheul, R., Van den Brink, W. (2005) Comorbidity of Personality Disorders and Substance Misuse Disorders in Kranzler, H.R. & Tinsley, J.A. (ed) Dual Diagnosis and Psychiatric Treatment: Substance Misuse and Cormorbid Disorders. Marcel Dekker. New York