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Dual Diagnosis Detox with ADHD

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The coexistence of a substance use disorder and mental health condition, such as Attention-Deficit/Hyperactivity Disorder (ADHD), is known as a dual diagnosis. People with a dual diagnosis may benefit from completion of specialized detox followed by a comprehensive addiction treatment program in order to adequately address both conditions.

Co-occurring Disorders

To be given a dual diagnosis means that a person has both a substance use disorder, or addiction, and a mental health disorder. Dual diagnoses are common; in fact, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports that approximately 7.9 million adults met the criteria for a dual diagnosis in 2014 alone.1,2

Approximately 7.9 million adults met the criteria for a dual diagnosis in 2014 alone.

People with substance addictions compulsively use substances, such as alcohol, prescription medications, or illicit drugs, despite the adverse psychological, financial, emotional, or physical consequences. Addiction is a progressive condition, which means that it tends to worsen over time, as the user often increases the amount, intensity, and frequency of substance use. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines several criteria used to diagnose substance use disorders. A few examples of these include:3

  • Needing and taking more of the substance to achieve the desired effect (tolerance)
  • Experiencing withdrawal symptoms when abruptly stopping use
  • Feeling strong cravings to use the substance
  • Having the desire to reduce or stop using the substance, but being unable to do so
  • Continuing to use despite issues with relationships, work, school, or finances
  • Using the substance in larger amounts or for longer periods of time than intended
  • Taking the substance in physically hazardous situations, e.g. driving or operating equipment

The DSM-5 classifies ADHD under neurodevelopmental disorders; it consists of a pervasive pattern of inattention, hyperactivity-impulsivity, or a combination of both. Inattention symptoms include the following:3

  • Inability to pay attention to details or continuously making careless mistakes at school, work, or other activities
  • Difficulty sustaining attention in tasks or activities
  • Difficulty listening
  • Often loses important things and is forgetful in daily activities
  • Inability to follow through on specific instructions
  • Problems with organization
  • Often becomes distracted by external stimuli

Hyperactivity and impulsivity symptoms include the following:3

  • Consistently moving around, e.g. fidgeting, tapping hands, leaving the seat, running or climbing in inappropriate settings
  • Often seeming to be “on the go” and unable to sit still for an extended time
  • Excessive chattiness
  • Frequently interrupting others
  • Difficulty waiting one’s turn
  • Inability to play or engage in activities quietly

The DSM-5 further indicates that people can be diagnosed with ADHD with the following specifiers:3

  • Predominantly inattentive presentation
  • Predominantly hyperactive/impulsive presentation
  • Combined presentation

For diagnostic purposes, symptoms must begin during childhood (before 12 years of age), and they must be present in at least two settings, e.g. both in school and at home.3

As mentioned, there is a high prevalence of comorbidity between substance use disorders and mental illness.4 It is often challenging, and sometimes impossible, to isolate which disorder developed first or to know if one arose in direct association with the other. However, it is clear that, left untreated, substance addictions and ADHD may worsen the clinical course of each other. Research does show that mental illness can alter brain chemistry, which may in turn increase vulnerability to the rewarding effects that mood-altering substances provide. Moreover, people with all forms of mental disorders (ranging from subacute to severe) may gravitate toward drugs or alcohol in attempts to self-medicate unwanted symptoms associated with mental illness.4

Woman experiencing symptoms of heroin overdose

An additional possible pathway to addiction involves the fact that ADHD is often managed with prescription stimulants, such as Adderall. Though perhaps not to the extent of cocaine, methamphetamine, and other psychostimulant drugs, these medications do have some inherent abuse and addiction potential, so a child or adult who is prescribed it for the treatment of ADHD may begin to abuse it by using larger amounts or taking more frequent doses than directed or in ways other than directed, such as crushing and snorting the pill or dissolving in fluid and injecting. Using a prescription stimulant in such a manner can increase the risk of developing an addiction. Though these prescription medications may not significantly increase addiction risks when used to treat kids with ADHD, they should still be combined with counseling and education about the risks.5

Both substance addictions and psychiatric conditions share risk factors that include:4

  • Genetic vulnerabilities (about 40­–60% of a person’s susceptibility to drug or alcohol addiction may be related to genetics).
  • Epigenetic and environmental influences.
  • Chronic stress, which can influence gene expression—something that can ultimately alter neuronal pathways and lead to behavioral changes.
  • Aversive childhood experiences and trauma.

Research shows that untreated childhood ADHD may increase the risk of developing a substance use disorder.5 For this reason, it’s important for the parents of children with possible behavioral and attention problems to seek out a counselor who can properly assess your child. Likewise, if you are an adult who struggles with ADHD-like symptoms and/or substance abuse, you’ll want to receive a professional evaluation.

Dual Diagnosis Evaluation

Due to the prevalence of dual diagnosis, all patients receiving treatment for alcohol or drug addictions should receive comprehensive evaluations for co-occurring mental health disorders and vice versa.6,7

Health professionals, such as psychiatrists, therapists, and social workers, perform biopsychosocial assessments to evaluate both the patient’s mental health and substance use history and a possible relationship between these disorders. It is common to ask questions related to the patient’s childhood, school and work performance, relationships with family and peers, and self-esteem, as this information helps paint a picture regarding one’s level of functioning. In general, this initial information provides the pathway for creating a customized treatment plan that integrates appropriate ADHD and substance abuse treatment.

Because it can be challenging to untangle overlapping or shared symptoms associated with drug use and mental illness, most medical professionals need to observe the patient after a period of sustained abstinence to provide proper diagnoses and rule out symptoms resulting from any residual substance intoxication or withdrawal.7

Substance Withdrawal & Detox Process

Suddenly quitting drugs or alcohol often results in the emergence of withdrawal symptoms. The manifestation of withdrawal symptoms depends on several factors, including:

  • Mental health status.
  • Physical health.
  • Type of substance used.
  • Frequency of substance abuse.
  • Amount typically used.
  • Length of drug or alcohol abuse.
  • Individual physiology.
  • Age.

Withdrawal symptoms exist on a spectrum, ranging from mild and unpleasant discomfort (such as fatigue or cravings) to extreme pain and even life-threatening symptoms (such as delirium tremens or seizures).8

It can be difficult to confidently separate some active ADHD symptoms from the features of several drug and alcohol withdrawal syndromes, since they can resemble and, at times, exacerbate one another. For example, someone who struggles with ADHD may fidget excessively or appear as jittery, while withdrawal from certain substances can result in psychomotor agitation, which can present as repetitive, purposeless movements.3

This overlap in potential symptoms can obscure a precise diagnosis as well as complicate withdrawal, which is why it’s important that a person struggling with a substance addiction receive professional detox services to keep them safe during withdrawal.

Professional Dual Diagnosis Detox Services

Professional detox services can appropriately address the unique symptoms associated with both disorders. The goals of detox include managing acute intoxication and withdrawal, evaluating and determining a patient’s current level of intoxication and substance use, and screening for co-occurring physical and psychiatric disorders. Another goal of detox includes facilitating the patient’s transition into dual diagnosis treatment once they complete detox.8

Detox can take place in many different settings, but medical inpatient facilities provide an environment particularly suited to people struggling with co-occurring disorders. These facilities offer 24/7 monitoring, supervision, and support in a safe location physically separated from the individual’s drug-using environment. This structure provides patients with a maximum number of resources, ranging from medications for withdrawal, psychotherapy groups, and timely access to a professional treatment team.

Once the substances have been eliminated from your body and you are stable, then the treatment team can effectively diagnose you and refer you to an appropriate dual diagnosis rehab facility.

Promoting Lasting Changes

Completing detox alone does not constitute appropriate or comprehensive substance abuse or mental health treatment. While detox helps provide a foundation for recovery, it does not offer the education, coping strategies, or structure often needed for someone to maintain sobriety in the long-term.

Rehab centers offer medical services and other therapeutic interventions to help manage substance use disorders. Dual diagnosis rehab centers focus on both the substance use disorder treatment and mental health issues, such as ADHD.

Rehabilitation offerings often include the following components:

  • Clinical treatment teams that provide comprehensive treatment and aftercare planning, including a therapist, case manager, psychiatrist, medical doctor, and treatment technicians
  • Positive and sober peer support
  • Education on coping and life skills
  • A variety of group therapy modalities focusing on several issues, e.g. relapse prevention, self-esteem, meditation, and/or family dynamics
  • Management and support for external stressors, e.g. housing issues, employment, and/or legal problems

Specialized ADHD treatment can reduce symptoms and improve a person’s ability to engage in daily tasks and activities.

Medication: Medications can help reduce ADHD symptoms. Doctors commonly prescribe stimulants, such as Adderall or Ritalin to manage ADHD. They work by increasing dopamine and norepinephrine in the brain.9 However, these substances can be addictive, so they are not advisable in those with substance addictions. With that said, treatment might involve ADHD-specific non-stimulants, such as Strattera. These are often an alternative course of action if the patient has struggled with addiction.9

Behavioral therapy: This type of therapy, which may be differently applied towards children, adolescents, and adults, works to promote and reward positive behaviors, identify how thoughts and behaviors impact a person’s interactions with others, and organizational and family-interaction skills. It implements adaptive coping strategies while reducing problematic behaviors.9

Stress management techniques: These might include coping methods such as yoga, exercise, and mindfulness, all of which can reduce stress levels and decrease ADHD symptoms.9

Family therapy: This type of therapy can improve communication, help address problems within the family unit, and teach the family members of an ADHD-affected individual how to support their loved one.9

Whether you or a loved one struggles with a dual diagnosis, it’s normal to feel angry, scared, or frustrated. Help is available and recovery is possible. It’s important to reach out for support to make that first step toward change.

Sources

  1. Substance Abuse and Mental Health Services Administration. (2017). Mental and Substance Use Disorders.
  2. National Institute on Drug Abuse. (2018). Common Comorbidities with Substance Use Disorders.
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  4. National Institute on Drug Abuse. (2018). Why is there comorbidity between substance use disorders and mental illnesses?
  5. National Institute on Drug Abuse. (2018). Part 1: The Connection Between Substance Use Disorders and Mental Illness.
  6. Abou-Saleh, M. (2004). Dual diagnosis: management within a psychosocial context. Advances in Psychiatric Treatment, V. 10 (5).
  7. National Institute on Drug Abuse. (2018). What are some approaches to diagnosis?
  8. Substance Abuse and Mental Health Services Administration. (2006). Detoxification and Substance Abuse Treatment.
  9. Substance Abuse and Mental Health Services Administration. (2017). Attention Deficit-Hyperactivity Disorder (ADHD).

 

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