Co-Occurring Disorders: Symptoms, Causes, & Treatment

By Audrey Howitt, LMFT

The term “co-occurring disorders” describes the presence of both a substance use disorder and one or more mental health disorders. This condition is also commonly referred to as “dual diagnosis” or “comorbidity.”

According to the National Survey of Drug Use and Health, around 20.4 million Americans had a substance use disorder in 2019. Further, around 9.5 million U.S. adults had co-occurring mental health disorders. In other words, nearly half of those who struggled with a substance use disorder also struggled with a mental health condition.

There’s a staggering correlation between substance use and mental health, so it’s important to understand why co-occurring disorders occur and how they can be treated. The following overview covers co-occurring disorders, the risks they create and the types of treatment available.

Symptoms of Co-Occurring Disorders

The Diagnostic Statistical Manual of Mental Disorders (DSM-5) does not list specific criteria or symptoms for co-occurring disorders. Instead, each mental health disorder has its own set of symptoms and criteria to make a diagnosis.

Co-occurring disorders of any kind can profoundly affect a person’s daily life. They often impact a person’s day-to-day tasks, relationships and careers by causing a variety of negative symptoms. These symptoms can include:

  • Thoughts or plans of suicide
  • Irritability
  • Isolation
  • Lack of social engagement with others
  • Lack of personal hygiene
  • Lack of engagement in normal activities
  • Changes in eating or sleeping
  • Feelings of euphoria or lethargy
  • Mood swings
  • Changes in sexual patterns
  • Hallucinations, paranoia and delusions

Common Co-occurring Disorders

Co-occurring disorders can include a broad range of substance use and mental health disorders. However, some combinations occur more frequently.

Depressive Disorders

Depressive disorders range from relatively mild but chronic depression (dysthymia) to deep depression (major depressive episode). Other types of depressive disorders include seasonal affective disorder (SAD), which typically occurs due to the low light of winter, and atypical depression, which is a type of depression that doesn’t quite fit in other categories.

  1. Alcohol use and depression occur together frequently, often as a form of self-medication. However, this can cause depression symptoms to worsen over time. Other disorders that commonly co-occur with depression include anxiety, bipolar disorder, post-traumatic stress disorder (PTSD) and borderline personality disorder.

Anxiety Disorders

Anxiety is a regular part of life. However, when someone experiences anxiety for prolonged periods or it disrupts other parts of life, they may have an anxiety disorder. Anxiety disorders include a variety of conditions, such as:

  • Social anxiety: Fear or anxiety in social or performance settings
  • Panic disorder: Panic attacks and fear of panic attacks
  • Generalized anxiety disorder (GAD): More generalized than specific anxiety
  • Agoraphobia: Fear of open spaces
  • PTSD: Often associated with trauma

Anxiety is highly associated with substance use. Alcohol, marijuana and other substances are often used to calm the symptoms of anxiety. However, substance use can make anxiety symptoms worse over time. Anxiety also frequently co-occurs with depression.

Psychotic Disorders

Psychotic disorders can generally be viewed as thought disorders — disorganized thinking that leads to difficulty in speech, conversations, writing and other aspects of daily living. Psychotic disorders include schizophrenia, delusional disorder and substance-induced psychotic disorder. These conditions are characterized by:

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly odd behaviors
  • Lack of facial expressions

Severe psychotic disorders are linked to high levels of alcohol, marijuana and other recreational drug use. Other conditions that co-occur with psychotic disorders include depression, anxiety and certain personality disorders.

Personality Disorders

Personality disorders involve certain personality traits that typically appear in the teen or early adult years. These traits and their associated behaviors deviate substantially from cultural norms and cause distress in relationships, at work and in social settings.

The DSM-5 lists ten personality disorders clustered in three groups:

  • Cluster A (odd or eccentric behaviors): Paranoid, schizoid, schizotypal
  • Cluster B (dramatic, emotional or erratic): Antisocial, borderline, histrionic, narcissistic
  • Cluster C (anxious or fearful): Avoidant, dependent, obsessive-compulsive

Co-occurring substance use disorders are common in these groups, especially in the borderline, avoidant, paranoid and antisocial groups. Personality disorders co-occur in 34.8% to 73.0% of people with substance use disorders.

Bipolar Disorders

Commonly known as manic depression, bipolar disorders are mood disorders marked by extreme highs (mania) and lows (depression) in mood. These mood swings vary from person to person. Some people have extreme highs and lows, while others experience more lows and infrequent or less intense highs. Others feel both the highs and lows occurring closely together.

People with bipolar disorder often experience anxiety, substance abuse, eating disorders and psychotic symptoms during extreme periods of mania or depression. Other co-occurring disorders include anxiety and substance use.

Eating Disorders

Eating disorders are pervasive patterns of thoughts, feelings and behaviors regarding food. These patterns cause significant physical distress and can be life-threatening when not treated. Common eating disorders include:

  • Anorexia nervosa (food restriction)
  • Bulimia nervosa (purging or excessive exercise after eating)
  • Binge eating disorder (a cycle of excessive eating coupled with purging or excessive exercise)

It’s estimated that over 20 million people worldwide are affected by eating disorders at some point in their lives. However, a new study suggests that this number may have been underestimated. Eating disorders often co-occur with depression, anxiety, obsessive-compulsive disorder and substance abuse. Eating disorders affect more women than men.

Substance Use Disorders

The substance use disorder classification covers a wide variety of addictions caused by alcohol, drugs and prescription medications. The DSM-5 uses several criteria when looking at how a person’s substance use affects their life. These criteria include:

  • Amount and duration of use
  • Inability to cut down or stop use
  • Time spent obtaining, using and recovering from substances
  • Cravings
  • Inability to perform at work, home or school due to substance use
  • Continued use despite relationship problems caused by substance use
  • Missing important social, occupational or recreational activities due to substance use
  • Using substances even when it puts you in danger
  • Using substances even though they worsen physical or psychological issues
  • Needing more of the substance to get the same effect (tolerance)
  • Withdrawal symptoms

The more criteria someone meets, the more severe their substance use disorder. Approximately one in 12 American adults have a substance use disorder, and about 8% of the population has both a substance use disorder and a co-occurring mental health condition.

Risk Factors for Co-occurring Disorders

Factors that can increase the risk for co-occurring disorders include:

  • Family history: Genetics can predispose someone to having a co-occurring disorder. For instance, genes are responsible for around 40% to 60% of a person’s risk of developing a substance use disorder.
  • Socioeconomic factors: The stress of poverty and similar socioeconomic factors, such as lack of health care access and education, create significant risk factors for co-occurring disorders.
  • Gender: Men may be at higher risk for co-occurring disorders than women. The 2019 National Survey on Drug Use and Health shows that in the U.S., approximately 4.9 million adult men and 4.6 million adult women have both a substance use disorder and a mental health disorder.
  • Trauma: People who suffer trauma are particularly at risk for co-occurring disorders. People with traumatic childhood experiences, as well as military veterans with PTSD, tend to use substances to help cope.
  • Mental health and medical history: When a person struggles with their mental health, they may turn to alcohol or other substances in an attempt to self-medicate. For example, depression and alcohol use are often linked. Because alcohol is a central nervous system depressant, however, it can make feelings of sadness, loneliness and isolation much worse. The same is true for other mental health conditions.
  • Substance abuse history: Substance use can change parts of the brain in the same way that mental illnesses like schizophrenia, anxiety, mood, or impulse-control disorders can. This can increase the risk of developing these mental health conditions.

Treatment Options for Co-occurring Disorders

Until recently, many believed it was more helpful to treat a person’s substance use separately from their mental health issues. Now, the best available approach involves providing integrated care that treats the co-occurring issues together.

Getting an accurate diagnosis of all co-occurring disorders is an important first step. Dual diagnosis treatment is often team-based and focuses on helping the client in a variety of ways. Treatment may include:

  • Taking appropriate medication
  • Undergoing medical detox
  • Participating in individual and group counseling
  • Learning skills that help manage disorders
  • Participating in treatment that targets mental health issues; for example, meditation may be used to help address anxiety
  • Attending 12-step recovery support meetings
  • Recovering in residential or outpatient treatment settings, depending on the client’s needs and preferences

Take the First Step

If you are currently struggling with a moderate to severe addiction and a co-occurring disorder, The Recovery Village can help. Our rehab centers offer evidence-based, compassionate care with licensed professionals. They’ll develop a personalized treatment plan to fit your needs, including dual diagnosis, medical detox, therapy and more. Contact our helpful representatives to get started on the path to recovery.

If you are already in recovery from substance use or a co-occurring mental health condition, the Nobu mental wellness app offers free tools and resources to help guide you through the rest of your journey. The app also provides access to licensed therapists for an additional cost, which may be covered by your health insurance provider. Take the first step toward reaching your mental wellness goals by downloading the Nobu app on the App Store or Google Play store today.

Edited by – Jonathan Strum Jonathan Strum graduated from the University of Nebraska Omaha with a Bachelor’s in Communication in 2017 and has been writing professionally ever since. He has written, edited and published content for health care professionals, educators, real estate agents, lawyers and high-level university faculty… Read more.
Written by – Audrey Howitt, LMFT Audrey Howitt is a Marriage and Family Therapist licensed through the California Board of Behavioral Sciences. She has eight years of experience working with clients in a variety of fields including addiction, dual diagnoses depression, anxiety, and deep insight work. She also has significant experience working… Read more.
dr angela phillips

Medically Reviewed by – Dr. Angela Phillips

Angela is a licensed therapist and clinical researcher, and has worked in public, private, government, and not-for-profit organizations, across clinical and research-oriented roles. Angela’s clinical and research experience has included suicide prevention, cognitive behavioral… Read more.