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    What is Comorbidity or Co-Occurring Disorders?

    Comorbidity, often described as co-occurring disorders (COD), describes two or more diseases or illnesses occurring in the same person. These disorders can occur at the same time, or one disorder may precede the other disease. Comorbidity also implies interactions between the illnesses that can worsen the course of both.

    Is Drug or Alcohol Addiction a Mental Illness?

    Drug and alcohol addiction is a form of mental illness.  The abuse of drugs or alcohol changes the brain in fundamental ways, which results in changing a person's desires and normal needs and replacing them with new priorities focused on seeking and using the drug.  These changes result in addictive and compulsive behaviors that further weaken the individual's ability to control impulses regardless of the negative consequences.

    How Common are Co-occurring Disorders of Substance Use Disorders and Other Mental Illnesses?

    Many people who have a substance use disorder also develop other mental illnesses.  Likewise, many people who are diagnosed with mental illness are often diagnosed with a substance use disorder.  Research has shown that nearly half of people who experience a mental illness will also experience a substance use disorder at some point in their life (Ross & Peselow, 2012; Kelly & Daley, 2013).

    Why Do Mental Illness and Addiction Disorder Co-Occur?

    The development of a dual diagnosis can lead to a cycle of self-destruction.   Individuals who struggle with a mental illness may turn to drugs or alcohol to cope with the anxiety, depression, or trauma.  In doing so, alcohol or drug abuse worsens the mental health of the individual.  As a result, more substances are used over a more extended period, resulting in an increased dependence on substances.

    Likewise, the abuse of drugs or alcohol increases the risk of the development of mental illnesses.   Research has shown that individuals with drug use in the past year were 1.4 times as likely to experience clinical depression, 1.6 times as likely to have post-traumatic stress disorder (PTSD), and 1.8 times as likely to have a borderline personality disorder compared to people without drug use disorder.

    While mental illness and substance use disorders commonly occur and coexist, this does not mean that one caused the other, even if one appeared first.   In fact, establishing which disease came first or why can be difficult.  Research suggests three possibilities for this common co-occurrence:

    • Common risk factors can contribute to both substance use disorders and mental illness.:  Research studies suggest that many genes can contribute to the risk of developing a substance use disorder and/or a mental illness.   Environmental factors, such as stress or trauma, can cause genetic changes passed down through generations.  These genetic changes that are passed down increase future generations' risk of developing either substance use or mental health disorder, or the comorbidity of both.
    • Mental illnesses can contribute to drug or alcohol use and substance use disorders.   Some types of mental health conditions have been identified as risk factors for developing a dependency on drugs or alcohol, increasing the risk of developing a substance use disorder (Baigent, 2012).   Research suggests that individuals may self-medicate with drugs or alcohol to attempt to cope with the various symptoms of mental illness (Santucci, 2012; Gill, 2014).   Although some drugs may help with mental illness symptoms, sometimes these substances can also worsen the symptoms.  Additionally, when a person develops a mental illness, brain changes may enhance the rewarding effects of substances, predisposing the person to continue using the substance regardless of the negative consequences (Santucci, 2012).
    • Drug or alcohol use and addiction can contribute to the development of mental illness.  The abuse of drugs or alcohol may change the brain to make a person more likely to develop a mental illness.  Each substance reacts with the brain in different and distinct ways, and the chronic abuse of substances alters the way that the brain functions.  These alterations increase the risk of the formation of mental illness.
    • Social factors can contribute to mental illness and substance use disorders.  We do not live life in a vacuum.  We are born to be in relationships with others.  However, these relationships can have a profound impact on us in either positive or negative ways.  The biological view of addiction only accounts for about 50% of the reasons to explain why someone abuses drugs or alcohol.  The other 50% are attributed to social factors.  The family, culture, and influence of friendships contribute greatly to the risk and protective factors of both substance use or mental illness.
    • Traumatic factors can contribute to mental illness and substance use disorders.  Trauma is often at the root of many mental health disorders.  Traumatic events are closely tied to depression, anxiety, eating disorders, borderline personality disorder, acute stress disorder, post-traumatic stress disorder (PTSD), and others (SAMHSA, Trauma-Informed Care in Behavioral Health Services: Treatment Improvement Protocol (TIP) Series 57, 2014).  Likewise, drugs or alcohol are often abused as a maladaptive coping strategy to deal with the pain, thoughts, and emotions associated with the traumatic event.  The experience of trauma is a personal one, and what may be traumatic for one person may not be traumatic for others.  Impactful trauma may be physical or sexual abuse. Still, trauma can also include emotional abuse, abandonment, neglect, or vicarious trauma where the individual is traumatized by seeing or hearing about a traumatic event.
    • Relationship attachment security factors can contribute to mental illness and substance use disorders.  Our attachment style, the way that we connect with others, is formed in childhood. The interactions between the child and the primary caregivers create an internal working model representing the child's beliefs about self, others, and the future (Delvecchio, Di Riso, Lis, & Salcuni, 2016). Our attachment style influences our perceptions of emotional intimacy, communication style, response to conflict, and relationship expectations. Research has shown that the degree to which people can regulate emotions is determined by the strength of their earliest attachment experiences (Flores, 2001).  Research has shown that insecure attachment styles correlate to interpersonal problems, emotional distress, and behavioral addiction or substance abuse (Gill, 2014).

    How Are These Co-Occurring Disorders Diagnosed?

    Due to the high rate of comorbidity between substance use disorders and mental illness, a comprehensive approach is necessary to evaluate and identify both types of diseases.  Anyone seeking help for mental illness or substance abuse should be evaluated for both and remain open-minded to have both disorders treated accordingly.

    However, the abuse of drugs or alcohol makes it difficult to diagnose mental illness accurately.  For example, the side effects of some substances, such as methamphetamines, can mimic the symptoms of severe mental illness.  A period of sustained sobriety may be necessary for a trained professional to diagnose any underlying mental illnesses accurately.  It may be necessary to establish a provisional mental health diagnosis. After various periods of sustained abstinence from drugs and alcohol, reassess to ensure the mental health diagnosis accuracy.

    How Are These Co-Occurring Disorders Treated?

    Integrated Dual Disorder Treatment (IDDR) is an evidence-based practice. Research has shown this combined treatment of the addiction with the underlying mental illness is one of the most effective strategies available and demonstrates consistent and positive outcomes (SAMHSA, 2009).  Several evidence-based practices have shown to be promising for treating comorbid conditions.   Each of these therapies can be tailored to patients according to age, the specific drug misused, and other factors.   These therapies can be used alone or in combination with medications.   Some effective behavioral therapies for treating comorbid conditions include:

    • Cognitive-behavioral therapy (CBT) helps change harmful beliefs that contribute to negative emotions and maladaptive or self-destructive behaviors.
    • Dialectical behavioral therapy (DBT) was designed specifically to reduce self-harm behaviors, including suicide attempts, thoughts, or urges, cutting, and drug use.  DBT is rich with skill development focused on distress tolerance, emotional regulation, and interpersonal functioning.
    • Contingency management (CM) recognizes and rewards healthy behaviors by providing vouchers or rewards.
    • Behavioral Family Therapy or Multisystemic Family Therapy recognizes the importance of relationships and the impact these can have on negative emotions and dysfunctional behaviors and looks to improve family relationships to help with mental health and substance abuse.

    PUSH for Recovery understands how underlying mental health struggles can contribute to substance abuse.  Call PUSH for Recovery today to begin your journey of healing from drug or alcohol addiction and the associated COD mental health disorders.


    Baigent, M. (2012). Managing patients with dual diagnosis in psychiatric practice. Current Opinions in Psychiatry, 201-205.

    Delvecchio, E., Di Riso, D., Lis, A., & Salcuni, S. (2016). Adult attachment, social adjustment, and well-being in drug-addicted inpatients. 118(2), 587-607.

    Flores, P. J. (2001). Addiction as an attachment disorder: Implications for group therapy. 51(1).

    Gill, R. (2014). Addictions from an Attachment Perspective: Do Broken Bonds and Early Trauma Lead to Addictive Behaviours. London: Karnac Books, LTD.

    Kelly, T., & Daley, D. (2013). Integrated treatment of substance use and psychiatric disorders. Social Work in Public Health, 388-406.

    Ross, S., & Peselow, E. (2012). Co-occurring psychotic and addictive disorders: neurobiology and diagnosis. Clinical Neuropharmacol, 235-243.

    SAMHSA. (2009). Integrated Treatment for Co-Occurring Disorders: Building Your Program. Rockville, MD: Substance Abuse and Mental Health Services Administration.

    SAMHSA. (2014). Trauma-Informed Care in Behavioral Health Services: Treatment Improvement Protocol (TIP) Series 57. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA).

    Santucci, K. (2012). Psychiatric disease and drug abuse. Current Opinion Pediatrics, 233-237.


    Donate to help the Life Recovery Society provide a safe, sober, supportive, and flexible way for individuals to earn an income while in treatment.  Life Recovery Society also plans to add a men's and women's sober living home in the Hilltop Community.