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Co-Occurring Disorders

Mental health issues and addiction frequently go hand-in-hand. Discover why it’s critically important to address both.

The importance of thorough diagnosis.

Mental health issues and addiction frequently go hand-in-hand. People who abuse drugs and alcohol commonly suffer from conditions such as anxiety, bipolar, eating disorders and more at the same time. Correctly and thoroughly diagnosing addicts is a necessary precursor to effective treatment.

At Caron, we can help you build a treatment program that meets your needs.

Co-occurring Disorders

The term co-occurring disorders, or dual diagnosis, describes the diagnosis of individuals who simultaneously suffer from mental illness and substance abuse problems. Alcohol and drug problems commonly co-occur with depression, anxiety disorders, schizophrenia, and/or personality disorders.

The concept of dual-diagnosis can be used broadly. In fact, many debate the suitability of this term, because it applies to a heterogeneous group of individuals with complex needs and a varied range of problems. For example, all of the following combinations could be considered co-occurring disorders:

  • Depression & alcoholism
  • Severe mental illness (psychosis, schizophrenia) & substance misuse disorder (marijuana abuse)
  • Mild mental (panic disorder, generalized anxiety disorder) & drug dependency
  • Intellectual disability & mental illness

Making a dual diagnosis in substance abusers is difficult, as drug abuse often induces psychiatric symptoms. It is necessary to differentiate between substance induced and pre-existing mental illness.

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Anxiety Disorders

Anxiety disorders are some of the most common mental illnesses. Five major types of anxiety disorders include generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD) and social anxiety disorder.

Generalized Anxiety Disorder

Generalized Anxiety Disorder is a constant, chronic state of worry and tension. People with GAD report always feeling anxious. They worry about almost everything, even when they know that their fears are unjustified.

Symptoms of GAD include an inability to relax, difficulty concentrating, an elevated startle reflex, trouble sleeping and physical problems like headaches, fatigue, muscle aches and tension, trembling, sweating, nausea, diarrhea and hot flashes. When severe, GAD can make it nearly impossible to complete simple, everyday tasks.

Obsessive Compulsive Disorder

People with obsessive-compulsive disorder suffer from upsetting thoughts (obsessions) and the continuous use of rituals (compulsions) to control the stress they cause. Though compulsions do reduce obsession-induced anxiety, relief is fleeting. Over time, compulsions become so severe that they interfere with daily life.

OCD can manifest in many different ways, but rituals usually relate to obsessions. Fear of fire, for example, may compel an individual to constantly check the stove to ensure that all the burners are turned off. People with OCD may have preoccupations with order and symmetry. They also may have difficulty throwing things away, which can result in hoarding behaviors.

Panic Disorder

Panic disorder involves sudden anxiety attacks that are usually accompanied by sweatiness, dizziness, a pounding heart and lightheadedness. Individuals undergoing panic attacks may experience nausea or diarrhea, chest pain, numbness or tingling in the hands, flushing or chills. Sufferers report feeling out of control and often feel as though they are experiencing a heart attack.

Panic attacks can occur any time (even during sleep) and can last for a few minutes or much longer. Usually, panic attacks begin to occur in late adolescence or young adulthood. People who have repeated, severe panic attacks are diagnosed with a panic disorder. This disabling condition can eventually lead to serious consequences, including agoraphobia, and appears to be inherited.

Post Traumatic Stress Disorder

Post-traumatic stress disorder occurs after a person is involved in, witnesses or is somehow exposed to any event that causes psychological trauma and affects the individual’s ability to effectively cope. Events can include, but are not limited to, warfare, death or threat of death, rape or other sexual trauma, torture, abuse, car accidents, fires, bombings or natural disasters.

Symptoms of PTSD include emotional numbness, loss of interest, irritability, aggression, anxiety, violence and difficulty sleeping. Often, PTSD sufferers experience flashbacks to the event. Occasionally, flashbacks are so real that the individual believes the event is reoccurring. PTSD is a severe condition that can extremely and negatively impact the individual and those around him.

Social Anxiety Disorder

Social anxiety disorder is characterized by feelings of overwhelming anxiety and self-consciousness in everyday social situations. Individuals suffering from social anxiety disorder have a chronic fear that they are being judged by others and/or will do something to embarrass themselves. Fear may be limited to specific types of events (eating in front of others, going on a date, meeting a new person) or could apply to broader scenarios (situations involving the opposite sex, interacting with non-family members, etc.). Often, persons with social anxiety disorder worry for days or weeks prior to these situations.

Social anxiety disorder can be both physically and psychologically debilitating. Physically, patients may suffer from blushing, sweating, trembling, diarrhea, nausea and stammering. Psychological effects include problems with work, school, family and friends. The sufferer may become isolated and, in extreme cases, housebound.

Anxiety and co-occurring disorders.

Because of the distressing, potentially debilitating effects of anxiety disorders, affected individuals may also suffer from co-occurring conditions, including depression and other anxiety disorders. Additionally, some may abuse drugs and alcohol to cope with their symptoms. When a dual diagnosis, such as an addiction or substance abuse problem, is present, the co-occurring condition must be treated first.

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Bipolar Disorder

Bipolar disorder is a mental illness characterized by episodes of elevated mood and energy levels (manic episodes) followed by episodes of extreme irritability and depression. It affects equal numbers of men and women, with typical onset between the ages of 15 and 25. While the cause of bipolar disorder is unknown, genetic factors are thought to play a role in its development.

Bipolar Symptoms.

Though manic and depressive phases vary in severity and degree, most patients experience similar bipolar symptoms. Symptoms of the manic, or elevated phase, include:

  • intense moods
  • increased energy
  • racing thoughts
  • excessive talking
  • delusions of grandeur
  • excessive self-esteem
  • reckless behavior
  • lack of control (including binge eating, drug and alcohol abuse and promiscuity)
  • short temper
  • poor judgment
  • little need for sleep
  • distraction
  • agitation

Manic phases occurs unpredictably and can last days or months.

The swing to the depressed phase can happen quite quickly (though sometimes a mixed state, in which both manic and depressive symptoms are present at once, follows manic episodes.) During the depressed phase, patients experience:

  • sadness
  • difficulty concentrating, remembering or making decisions
  • feelings of worthlessness
  • hopelessness or guilt
  • low self-esteem
  • loss of enjoyment
  • eating problems, including either loss of appetite and weight loss or binge eating and weight gain
  • insomnia or excess sleep
  • isolation from friends and family
  • thoughts of suicide and death

Individuals who suffer from bipolar disorder are often drawn to alcohol and drug abuse throughout both phases. Substance abuse can make bipolar symptoms worse and increase one’s risk of suicide.

Types of bipolar disorders.

There are several types of bipolar disorder:

  • Type I: Individuals have had at least one manic episode and experience periods of major depression. (In the past, Type 1 bipolar was called manic depression.)
  • Type II: Individuals have never had full mania. Instead they experience periods of high energy and impulsiveness that are not as extreme as mania. These periods, called hypomania, alternate with episodes of depression.
  • Clyclomythia: A mild form of bipolar disorder that involves less severe mood swings, cyclomythia involves periods of hypomania and mild depression.

People with bipolar disorder type II or cyclothymia may be mistakenly diagnosed as having depression.

Treating bipolar disorder

If you or a loved one needs help overcoming bipolar disorder, Caron is here for you. Please explore our support groups or contact us for more information.

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Body Image & Eating Disorders

Eating disorders wreak havoc on a person's health. The self-destructive behaviors associated with them not only impact physical health, they severely damage psychological health. Because many factors influence the development of eating disorders, treatment and recovery must address the unique needs of the whole person.

What are eating disorders?

Eating disorders are illnesses characterized by abnormal eating habits that adversely impact physical or mental health. Though eating disorders primarily affect females, particularly teenagers and young adults, males can also suffer from them.

Types of eating disorders.

The most common eating disorders are anorexia nervosa, bulimia nervosa and binge eating disorder.

  • Anorexia nervosa, which is characterized by an intense fear of gaining weight, involves very restricted eating and the pursuit of an extremely low body weight (at all costs.)
  • Bulimia nervosa involves recurrent episodes of binging (eating unusually large amounts of food) followed by compensatory behaviors such as vomiting, using laxatives or compulsive exercise.
  • Binge eating disorder involves compulsive episodes of overeating without the compensatory behaviors associated with bulimia nervosa.

Other eating disorders include compulsive overeating, pica (compulsive eating, chewing or licking of non-food items such as paper, cigarette ashes or chalk) and purging disorder (vomiting or other elimination behaviors in the absence of binging behaviors.)

Causes of eating disorders.

While the exact cause of these disorders is unknown, a combination of genetic, psychological, environmental and social factors is thought to play a role. Often, individuals suffering from eating disorders have low self-esteem, depression, anxiety, loneliness or other co-occurring conditions. Peer and cultural factors, including narrow definitions of beauty; the glorification of thinness; and an emphasis on appearance over character, may also contribute to the development of eating disorders. Genetic influences, such as a history of eating disorders in the family, may also be at play. Finally, individuals with eating disorders may have a history of physical or sexual abuse or other childhood trauma.

Effects of eating disorders.

Eating disorders can have serious physical and psychological consequences. Patients with eating disorders are often extremely malnourished. Many suffer from electrolyte imbalances, osteoporosis, constipation, diarrhea and dental problems. More serious complications, such as cardiac arrest, kidney failure, brain atrophy, death and suicide, also result from eating disorders.

Treating eating disorders.

The most effective eating disorder treatment programs approach individuals from a holistic perspective. These programs:

  • identify underlying causes of eating disorders
  • address psychological, biological, social and cultural factors that influence eating disorders
  • teach coping strategies
  • treat other health problems and co-occurring disorders

A typical course of eating disorder treatment.

Usually, eating disorder treatment programs involve behavioral counseling or psychotherapy; family counseling; nutritional counseling; and help from therapists, support groups and other experienced professionals. Medication may be used both to combat co-occurring mental health issues and to manage the many health problems that often arise from eating disorders.

While eating disorders can sometimes be treated in an outpatient setting, many patients flourish in the therapeutic, nurturing environments that residential or inpatient programs offer. Inpatient treatment or hospitalization may be necessary and beneficial for the following types of patients:

  • Individuals who have suffered from an eating disorder for a long time
  • Those with severe cases of the disorder
  • Those with comorbidities, such as drug addiction, anxiety or severe depression
  • Those with severe health complications

Hospitalization and inpatient treatment programs should be followed by continued outpatient treatment. Follow-up care and monitoring, which is essential for preventing relapse, should continue after outpatient treatment is complete.

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Anorexia nervosa is an eating disorder characterized by the desire to appear thin, the obsessive fear of gaining weight and body dimorphic disorder (distorted self image.) Though prevalent among teen girls, anorexia can affect anyone. People with anorexia feel hunger yet refuse to give their bodies enough food. Some eat as little as 600 calories a day, while others attempt total starvation. Sadly, anorexia is a serious psychiatric disorder that can be fatal if not effectively treated.

Symptoms of anorexia.

Individuals suffering from anorexia experience a variety of symptoms that may include:

  • Extreme thinness
  • Fear of gaining weight
  • Refusal to remain at a healthy weight
  • Obsessing about food
  • Feeling overweight despite extreme thinness
  • Using exercise, vomiting, diet pills or diuretics to maintain their ideal weight
  • Adamant denial of having a problem
  • Rapid weight loss
  • Lanugo (a soft, fine hair that grows on the face and body)
  • Bad breath
  • Interruption of menstrual cycle
  • Electrolyte imbalances
  • Swollen joints or cheeks
  • Distention of the abdomen
  • Hair thinning or loss
  • Low blood cell count
  • Low blood pressure
  • Acne
Causes of anorexia.

While anorexia’s causes are unclear, many anorexic people have a family history of eating disorders. Others begin dieting and trying to lose weight as a means of coping with stressors, like death in the family or divorce. In these cases, anorexia occurs when dieting spins out of control and disorder takes over. For some, perceived societal and cultural pressure to be thin are the driving forces behind the illness. Many anorexics are perfectionists striving for an unattainable ideal.

Treating anorexia.

Anorexia can become a lifelong struggle. If left untreated or treated too late, it can cause serious health problems such as starvation, osteoporosis, brain atrophy, kidney damage and cardiac arrest. Often, these problems can be fatal.

Early treatment, on the other hand, can be very effective. Usually, comprehensive treatment plans first focus on restoring the patient’s health by getting her back to a healthy weight. Next, co-occurring conditions are addressed. Finally, counseling, psychotherapy or other forms of psychiatric therapies are employed to address the initial behaviors and thoughts that caused the disease.

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Bulimia nervosa is an eating disorder that involves binging and purging behaviors. Binging, or episodes of excessive overeating, is usually characterized by a lack of control. To compensate for this loss of control and to avoid weight gain from binging episodes, bulimic people purge food by vomiting, abusing laxatives or diuretics, using enemas or exercising excessively. While purging behavior often brings temporary relief, it is usually followed by guilt. Bulimia usually affects more women than men and is most common in teens and young adults.

Causes of bulimia.

While the exact cause of bulimia is unknown, various genetic, psychological and social factors are thought to play a role in its development. Risk factors include:

  • A history of eating disorders or obesity in the family
  • Issues with control and perfectionism
  • Societal pressures to be thin
  • Job-related pressure to be thin (i.e. modeling or ballet)
  • Childhood trauma, such as sexual abuse
Diagnosing bulimia

People with bulimia are often normal weight, so the disease can be difficult to detect. Physical symptoms of bulimia vary, but may include:

  • Dental problems, such as cavities, tooth erosion or gum infections
  • Broken blood vessels in the eyes
  • Swollen cheeks
  • Acne or rashes
  • Small cuts across the finger joints from inducing vomiting
  • Electrolyte imbalances
  • Dehydration

People with bulimia may also overeat but not gain weight, go to the bathroom right after meals or act secretive about eating.

Treating bulimia.

If untreated, bulimia can result in a variety of complications, including constipation, hemorrhoids, pancreatitis and tears in the esophagus. Eventually, bulimic individuals may develop heart problems, kidney failure and osteoporosis.

If bulimia has not progressed to the point where hospitalization is needed, most treatment plans involve a combination of cognitive-behavioral therapy, medication and support groups. When co-occurring conditions (such as substance abuse or depression) are present, they may need to be treated first.

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Cutting & Self-injury

Self-harming, also known as self-injury, self-mutilation, self-inflicted violence or cutting, refers to a spectrum of disorders in which the individual inflicts harm on himself to relieve tension or respond to stressful situations. Self-harm is most common in adolescents, teens and young adults but can occur at any age. Though not a suicide attempt, cutting can result in serious injuries and accidental death.

Initially, self-harmers may engage in injurious behavior on impulse. When impulsive self-harm begets momentary calm and relief from tension, the behavior can become repetitive and addictive. Self-harmers continue to cut (despite the guilt that follows), because they crave temporary relief from stress and psychological pain.

While the majority of self-harmers engage in skin cutting behaviors, many other forms of self-harm exist. Individuals may also scratch, burn, pull out hair, break bones, hit, punch, pierce the skin, ingest toxic substances, bite, carve the skin or interfere with wound healing.

Risk factors associated with cutting and self-injury.

People hurt themselves for a myriad of reasons. In addition to relieving stress, anxiety or pressure, people cut to relieve feelings of gross inadequacy and a serious lack of self-esteem. Risk factors for self-injury include suffering from co-occurring disorders such as depression, bipolar disorder or phobia; a history of child abuse or other childhood trauma; and having friends who self-injure. Self-harmers also have an increased risk of suicide and substance abuse.

Signs of self-injury.

Self-injury is often kept secret, so it can be difficult to detect its signs and symptoms. Signs of self-injurious behavior may include, but are not limited to:

  • Scars, cuts, bruises or other wounds
  • Broken bones
  • Relationship troubles
  • Wearing long pants and long sleeves, even in hot weather
  • Isolation from friends and family
  • A tendency to keep sharp objects on hand
  • Claiming to have frequent accidents
  • Injuries on areas of the body that are easily reached (front of torso, arms and legs)
Treating cutting and self-injury

Treatment for self-harmers usually involves psychiatric treatment or cognitive-behavioral therapy. Therapy usually involves teaching the individual healthier coping strategies for dealing with the triggers that lead to to self-harm. Medical interventions may also be helpful, particularly in cases with co-occurring mental disorders. Inpatient treatment may be necessary for those at high risk for serious injury.

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What is Perfectionism?

Perfectionism is a compulsive pattern of behavior and thought that may begin in childhood as part of one’s natural traits or arise through circumstances and stress. It is only a problem if it has a detrimental effect on one's quality of life or conflicts with personal values. Those who have a serious problem with perfectionism often struggle with low self-esteem, repressed feelings, insecurity or shame. Trying to be perfect is not a conscious choice and, for those who are coping with chronic stress, it may become a long-term pattern of trying to maintain excellence in many areas of life.

Are all perfectionists the same?

There are two types of perfectionists. Overt perfectionists are easy to see; they are orderly, organized and a little uptight. They may be critical of others and hard to please. Some overt perfectionists are focused on social standards and how others should be.

Covert perfectionists do not appear perfect in many areas of life but have mental committees of critics. Covert perfectionists pressure themselves to be better, are very self-critical, make comparisons to others and often feel that they don’t measure up. They are especially challenged by relationships in which they do not feel adequate or good enough. Coverts tend to be more self-oriented—more concerned about their own performance than others.

How serious is it?

Perfectionism has been linked to anxiety, depression, suicidal ideation and suicide attempts. It is also related to lower relationship satisfaction and fear of intimacy.

How does perfectionism hurt relationships?

Perfectionists are sensitive and defensive about making mistakes or being blamed or criticized. They avoid vulnerability and openness and try not to appear flawed or bad. Since intimacy requires openness with emotions, their relationships may be superficial and focused on doing things for their partners rather than just being close. Some may also appear superior, expecting things to be done a certain way to the point of demeaning a partner.

How does it affect children when a parent is a perfectionist?

The overt perfectionist may become an enforcer or teacher rather than a loving parent. They value doing what is right or correct rather than allowing children to learn from mistakes and develop their own identities. At times it may seem that the parent's self-esteem is dependent on the success of the child. Some children will rebel; others will try to comply while hiding their imperfections and doubts from their parent.

How can this pattern be changed?

Change is a three-stage process. First perfectionists need to see and evaluate the pitfalls of perfectionism and how it began. If it is not a problem, it doesn't need to change. If it is causing problems or is not a reflection of your values, it is important to make changes. The second step, called Becoming Me, charges perfectionists to looks closely at who they really are. It is important to be real and slowly practice letting others see who you are. The third step is to let go of expectations and forgive yourself for past mistakes. It is a time to begin accepting yourself and others.

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Treating co-occurring disorders

To improve, individuals with co-occurring disorders must be treated for both conditions. First, the person must go through detoxification, the process of ridding the body of substances by abstaining from alcohol or drugs. The next step involves rehabilitation for the substance problem and treatment for the mental disorder. This might include medicines, support groups and one-on-one therapy.

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About Caron

With 60 years in the field, Caron Treatment Centers operates lifesaving addiction and behavioral healthcare treatment. Caron is headquartered in Wernersville, Pennsylvania with Ocean Drive and Caron Renaissance located in Palm Beach County, Florida. Caron has recovery centers in New England, Philadelphia and Washington, D.C., which offer community and recovery support. Caron’s Recovery Centers in Atlanta and New York City also offer pre- and post-treatment services. Caron has the most extensive continuum of care including teens, and adults, chronic pain, executives, healthcare professionals and legal professionals. Caron’s outcomes-driven treatment care plans are customized to meet the needs of individuals and families – with highly trained teams prepared to address co-occurring disorders. Caron offers an innovative approach to ongoing recovery care support for its former patients and their families with online peer groups and other resources during the first year of transition following discharge

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