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Dual Diagnosis Detox & Bipolar Disorder

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When someone is struggling with both a substance use disorder and bipolar disorder, the detox process can be impacted in several ways. It is essential that prospective patients and their loved ones understand what to expect during this initial step towards recovery.

Defining Dual Diagnosis

Struggling with addiction and mental health.Dual diagnosis, also referred to as co-occurring disorders, refers to the coexistence of both a substance use disorder, or addiction, and a mental health disorder, such as bipolar disorder. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that approximately 7.9 million adults had a dual diagnosis in 2014.1

Substance use disorders impact one’s psychological, interpersonal, and physical well-being. When left untreated, they can lead to fatal consequences, such as overdose.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), some of the signs and symptoms of a drug or alcohol addiction—or substance use disorder—include: 2

  • A persistent desire to reduce or abstain from the substance (but failing to successfully do so).
  • High cravings and urges to use the substance.
  • Persistent, continued use despite relationship, work, or academic problems.
  • Substance use in physically hazardous situations (e.g. drinking and driving).
  • Tolerance, or needing to take more of the substance to achieve the desired effect.
  • The presence of withdrawal symptoms when reducing or abstaining from substance use.
  • An excessive amount of time is spent obtaining, using, or recovering from the use of the substance.
  • Larger amounts of the substance are used than originally intended.

The bipolar disorders are a category of mental health issues characterized by both manic and depressive episodes. The DSM-5 indicates that both men and women experience bipolar disorder at similar rates, with the average onset occurring around age 18.2

There are several disorders that belong to the category of bipolar disorders. For example, there is bipolar I disorder, bipolar II disorder, cyclothymic disorder, and other specified and unspecified bipolar and related disorders that don’t match the first three categories.11 For this article, we will be focusing on bipolar I disorder.

To meet the criteria for having a bipolar disorder diagnosis, a person must have a history of the following:2

  • Manic Episode: Manic episodes last at least one week and consist of abnormally elevated mood and energy. The person may experience increased self-esteem and self-worth, reduced need for sleep, increased distractibility, racing thoughts, and compulsive behavior (promiscuous sex, excessive gambling, shopping).
  • Depressive Episode: Symptoms of a depressive episode must be present during a 2-week period and consist of depressed mood for most of the day nearly every day, reduced interest in normal activities, unintentional weight loss or weight gain, fatigue and lack of concentration, and feelings of worthlessness or guilt. Sometimes, people in a depressive episode experience recurrent thoughts of death and may attempt suicide.

Dual diagnosis represents a common phenomenon, with research suggesting that nearly half of those with a substance use disorder also have a mental health disorder, and vice versa.3

Doctors believe that substance addictions and mental health disorders can actually feed into each other. For example, many people begin experimenting with drugs during adolescence when the first symptoms of mental illness, such as depression or anxiety, may emerge.3

Furthermore, environmental factors, such as trauma or chronic stress, are both associated with an increased risk for developing both substance use and mental health disorders.4

Some people with mental health disorders, such as bipolar, may self-medicate in an attempt to control adverse symptoms. Drugs and alcohol may provide a temporary relief to manage this discomfort, but will ultimately worsen the psychiatric symptoms.4 Research suggests that using cocaine may exacerbate symptoms associated with bipolar disorder and may also play a key role in the progression of this condition.4

With dual diagnosis, it is not always possible to tell if one of the disorders caused the other, even if one of them appeared first.

Assessing a Co-Occurring Disorder

The importance of assessment.Because many symptoms of these disorders can overlap with one another, it can be challenging to properly assess and identify dual diagnoses. Anyone entering treatment for psychiatric support should be thoroughly screened for both substance use and mental health disorders, and anyone entering treatment for addiction should be evaluated for psychiatric symptoms. Doctors and mental health professionals will typically conduct a screening of a patient’s biopsychosocial history and evaluate the presence of their symptoms and their frequency, intensity, and duration.

For this reason, patients should undergo a comprehensive assessment to give treatment providers a more accurate diagnostic picture.5 An evaluation should include a thorough assessment of the following:5

  • The patient’s drug or alcohol abuse history and its interaction with bipolar disorder
  • The impact that drug or alcohol abuse has had on multiple facets of the patient’s life, such as housing, work, leisure, personal goals, and relationships
  • The risk of harming others or engaging in self-harm
  • The risk of blood-borne viral infections
  • The patient’s motivation to make positive changes
  • The patient’s preferences (if any) for detox and treatment
  • Immediate needs, such as medical conditions, mental health problems, and social needs

However, ideally a period of abstinence is necessary for accurate diagnosing. This is because the effects of substance intoxication and/or withdrawal symptoms can look like the symptoms present in bipolar disorder (i.e. depressed mood, lack of energy, poor concentration).5,6 If the bipolar symptoms are still present 4 weeks following detoxification, then this more strongly indicates a co-occurring mental health condition.5

There are several different screening tools that may be used in order to obtain a proper diagnosis. These include:5

  • The Psychiatric Research Interview for Substance and Mental Disorders, which has shown more reliability than previous tools for evaluating mental health conditions.
  • The Dartmouth Assessment of Lifestyle Instrument.
  • The Alcohol Use Disorders Identification Test.
  • The Drug Abuse Screening Test.
  • The Mini-Mental State Examination.
  • The Chemical Use, Abuse and Dependence Scale.
  • The Substance Abuse Treatment Scale

Reduced cognitive functioning will impact the evaluation process, as will many other general factors, such as cooperation, severity of bipolar symptoms, and motivation for change.

Withdrawal Symptoms & Complications

Withdrawal symptoms to recognize.Withdrawal symptoms emerge when someone who is dependent on a substance abruptly discontinues or dramatically reduces use. Withdrawal symptoms can be both physical (such as body aches and pains and flu-like symptoms) and psychological (such as depression, severe cravings, hallucinations).7 In general, these symptoms can range from mildly uncomfortable to extremely painful and distressing. Depending on the substance or combination of substances used, withdrawal can even be life-threatening.7

The symptoms of bipolar disorder may influence the severity of the withdrawal syndrome and, conversely, withdrawal can impact bipolar symptoms as well. For example, withdrawal from stimulants, such as cocaine or methamphetamine, often includes symptoms, such as:7

  • Depression.
  • Fatigue.
  • Anxiety.
  • Irritability.
  • Impaired concentration.
  • Paranoia.
  • Severe cravings.

Someone with a dual diagnosis involving bipolar disorder may experience a worsening of any depressive episodes present during the withdrawal period. Alternatively, the irritability associated with withdrawal could exacerbate a manic episode, or the other way around. Stimulant intoxication could also trigger a manic state in someone with bipolar disorder.7

Another example of a substance that can impact the course and severity of bipolar disorder is alcohol. Research indicates that alcohol withdrawal may actually trigger the symptoms of bipolar disorder.10

There is no clear one-way relationship when it comes to drug or alcohol withdrawal and bipolar disorder, but rather, co-occurring disorders are extremely complex and tend to impact each other in a bidirectional pattern.10

Furthermore, a sustained period of confirmed abstinence (at least 1-2 weeks) is typically sought before initiating treatment with mood stabilizers or other psychiatric medication appropriate for managing bipolar symptoms.7

Various factors, including heightened feelings of anxiety, depression, mania, substance cravings, and emotional discomfort can all complicate the withdrawal process. Therefore, medical professionals frequently recommend that patients seek dual diagnosis detox services to stay safe and supported during this difficult time. Specialized detox can provide patients with the initial stabilization and monitoring needed to address potential complications that can arise.

Detox for Addiction & Bipolar Disorder

Detox is the first step towards recovery.Detox treatment should integrate treatment elements to address both substance abuse and mental health issues, so that the treatment team can appropriately identify and address the unique needs present in both dual diagnoses.

Detox refers to a group of interventions intended to manage acute intoxication and withdrawal symptoms. During detox, the body clears itself of toxins associated with substance use. Detox procedure entails the evaluation of a patient’s substance use and mental health status, stabilization throughout intoxication and withdrawal, and appropriate referrals and entry into substance abuse treatment.7

While there are many different settings available for dual diagnosis detox, inpatient is a commonly utilized option. Medical inpatient detox provides 24/7 supervision, monitoring, and medical treatment. Patients have access to a comprehensive treatment team that includes medical and psychiatric professionals. This is especially important if complicated withdrawal symptoms arise during detox.7

Both bipolar and substance use disorders represent chronic, serious mental illnesses. When left untreated, there remains a high risk for impaired functioning and diminished quality of life. Appropriate treatment and support are essential for increasing one’s emotional and physical well-being.

Long-Term Treatment

Assessing options for recovery.Although detox often represents the first step towards recovery, it is not a substitute for longer-term dual diagnosis treatment. After completing detox, people are well advised to transition into ongoing treatment to learn the adaptive coping skills needed to manage drug cravings, triggers, and stressors.

The preferred model of treatment for those with a substance addiction and co-occurring bipolar disorder is integrated treatment. This means that the same staff members treat both conditions in the same location.5 An integrated dual diagnosis treatment program tailors the treatment plan to each individual patient and their unique treatment needs.

Some principles of integrated care for those struggling with substance abuse and bipolar disorder include:5

  • Utilizing outreach to improve engagement.
  • Providing concurrent treatment services.
  • Instilling hope and optimism in patients and those close to them.
  • Specialization, including changing approaches to cater to that specific person.
  • Achieving a stable living situation.
  • Exploring a wide range of treatment interventions.
  • Monitoring patients closely to provide encouragement, support, and structure.
  • Addressing each stage of treatment: engagement, persuasion, treatment, and relapse prevention.
  • Maintaining a longitudinal perspective for these chronic and often relapsing conditions.

Rehab facilities provide patients with continuous support and monitoring throughout their care. These facilities employ a variety of clinical services, including individual and group therapies, medication management, drug education, and aftercare planning, to teach people how to manage negative feelings and triggers, manage problematic symptoms, and improve their overall life functioning. A rehab facility that specializes in dual diagnosis treatment understands fully addressing the needs of both bipolar disorder and addiction. They work to treat both disorders simultaneously, rather than only focusing on one of them at a time.

Even though bipolar disorder does not have a cure, recovery is possible. Typical treatment methods include:8,9

  • Mood stabilizers: Lithium is the most commonly prescribed mood stabilizer, but Depakote and other anticonvulsants are also used to manage mood dysregulation and manic episodes.
  • Atypical antipsychotics: Medications, such as Seroquel or Zyprexa, may be prescribed alone or in conjunction with other psychiatric medications. Latuda, another atypical antipsychotic medication, was approved by the Food and Drug Administration (FDA) to manage bipolar-related depression.
  • Antidepressants: Antidepressants, such as Prozac, may be prescribed in conjunction with Zyprexa to manage depressive episodes. These two drugs are available in a combination capsule called Symbyax.
  • Cognitive-behavioral therapy (CBT): CBT teaches patients the relationship between thoughts, feelings, and behaviors. It helps them to identify their own harmful thought patterns, feelings, and behaviors so that they can rectify them and reduce the amount of emotional distress associated with stressful and troubling situations.
  • Interpersonal and social rhythm psychotherapy (IPSRT): This intervention has three components. First, patients receive education about bipolar disorder and treatment for it. They then develop ways to stabilize life patterns and routines. Lastly, patients learn how interpersonal dynamics impact mood changes and may trigger new episodes of depression or mania.
  • Family-focused therapy (FFT): This form of therapy promotes an understanding of bipolar disorder in family members of the patient. It helps family members to learn to recognize new manic or depressive episodes in their early stages. FFT can also improve problem-solving and communication skills amongst family members.

If you or a loved one is struggling with a dual diagnosis, it’s normal to feel scared, alone, or angry. With that said, help is available. Make a positive change today by reaching out to an appropriate dual diagnosis detox or rehab program.

Sources

  1. Substance Abuse and Mental Health Services Administration. (2017). Mental and Substance Use Disorders.
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  3. National Institute on Drug Abuse. (2018). Part 1: The Connection Between Substance Use Disorders and Mental Illness.
  4. National Institute on Drug Abuse. (2018). Why is there comorbidity between substance use disorders and mental illnesses?
  5. Abou-Saleh, M. (2004). Dual diagnosis: management within a psychosocial context. Advances in Psychiatric Treatment, V. 10 (5).
  6. National Institute on Drug Abuse. (2018). What are some approaches to diagnosis?
  7. Substance Abuse and Mental Health Services Administration. (2006). Detoxification and Substance Abuse Treatment.
  8. Substance Abuse and Mental Health Services Administration. (2016). An Introduction to Bipolar disorder and Co-Occurring Substance Use Disorders.
  9. National Institute on Drug Abuse. (2018). Common Comorbidities with Substance Use Disorders.
  10. National Institute on Alcohol Abuse and Alcoholism. (2002). Bipolar Disorder and Alcoholism.
  11. National Institute on Mental Health. (n.d.). Bipolar Disorder.

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