It is an age-old riddle that has perplexed us for generations; which came first, the chicken or the egg? (There is definitive scientific evidence that it’s actually the chicken – but that is not important.) In this article I focus on co-morbidity, which is the presence of two conditions which exist in a person simultaneously. My focus is the co-existence of addiction/alcoholism and a psychiatric illness, but there is also the co-existence of addiction/alcoholism and a medical illness. Both psychiatric and medical illnesses can be caused by the addiction – or they can be present coincidentally, that is, together with/alongside the addiction.
- The Addiction disease concept construct – from the The Jellinek Curve, modified by Max Glatt, a professor at Yale University in 1961 is:
- Drug use (apparent control)
- Drug misuse (poor control)
- Drug addiction (loss of control)
- Drug dependence (no control)
- “Rock bottom” (no purpose/no pleasure)
- Physical illness differs from mental illness in that symptoms can often be related to a cause and a standard treatment can be prescribed. Teggin (as cited in Hutton, 2011) describes medical illness co-morbidity, specifically alcoholics risk contracting the following medical illnesses:
- Cirrhosis of the liver
- Gastro-intestinal haemorrhaging and gastritis
- Alcohol-related dementia
- Wernicke-Korsakoff syndrome (“wet brain” or impairment of recent memory)
- Drug addicts, specifically risk contracting the following medical illnesses:
- Hepatitis C
- HIV and AIDS
- Infection of the heart valves
- Other infections, including abscesses
- Owing to the debilitating effects of alcohol and drug addiction, addicts may contract other medical illnesses such as:
- Nutritional disorders
- Tuberculosis (TB)
- Other infections and malignancies
In my clinical social work practice, specialising in addiction, I frequently come across psychiatric illness co-morbidity – or “dual diagnosis”, as it is also called.
“Mental illness” is most commonly defined by the criteria contained in the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) (Text Revised) (DSM-IV-TR) (American Psychiatric Association, 2000).
Mental illness is however, difficult to define, and there are different ideas about its causes. One theory is that its roots are organic (that is, owing to abnormal functioning in the brain) and that chemical imbalances in the brain lead to mental disorders. Another theory is that it stems from a difficult social environment or from “faulty” learning experiences that have led to inappropriate or unusual behavior. Such behaviour may be viewed as a sign of mental illness. The two factors actually overlap and interact. Organically rooted mental illness may lead to inappropriate behaviour, and unusual behaviour may lead to changes in brain chemistry. Mental illness is therefore not fixed; rather, it encompasses a broad range of conditions, interpretations and behaviours.
These days, many mental health professionals regard mental illness as a result of both “nature” and “nurture”. A simple definition taken from an unreferenced LifeLine Johannesburg training handout is, “A person is considered to be suffering from a major mental illness if he has developed a lifestyle that seriously impeded his ability to function in his day-to-day activities. Mental health, as defined by the World Health Organisation (WHO) “refers to a broad array of activities directly or indirectly related to the mental well-being component included in the WHO’s definition of health: ‘A state of complete physical, mental and social well-being, and not merely the absence of disease’. It is related to the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by mental disorders” (World Health Organisation, 2011). The WHO has also issued a new report in which they describe mental health and development. In the report they refer to the target group of “people with mental health conditions” as “a vulnerable group” (World Health Organisation, 2011).
As Teggin (as cited in Hutton, 2011, p. 79) has indicated, “Psychiatric conditions tend to be more complex than medical illnesses because they can either be caused by the alcohol or drug addiction, or they can co-exist independently, with or without Personality Disorder”. The author (as cited in Hutton) concludes, “Research shows that a person may have a genetic predisposition to both addiction and psychiatric illness. In other words any psychiatric illness can co-exist in an addict or alcoholic” (2011, p. 81).
Van Wormer and Davis (2003, p. 247) begin their chapter: “Substance misuse with a co-existing disorder or disability” with a metaphoric quote by Stevie Smith:
“I was much too far out all my life
And not waving but drowning”
Mental illness can be frightening when it spirals out of control. When combined with the misery, shame, guilt and consequences of alcohol/addiction, the result can be an unmanageable life – that can be likened “drowning”.
With regard to prevalence, Ries et al., (as cited in Doweiko) suggested that overall “between 40% and 75% of people who struggle with mental illness have a separate substance-use disorder” (2006, p. 292); Patrick; RachBeisel et al., (as cited in Doweiko) stated “In the early 21st century, it has become generally accepted that about 50% of patients with a form of mental illness will have a concurrent substance-abuse problem (2006, p. 292); and “The National Co-morbidity Survey found that 51% of persons with a lifetime addictive disorder also have a lifetime mental disorder” (Kessler, Nelson, & McGonagle, as cited in Van Wormer & Davis, 2003, p. 249). In fact, “There is evidence that the more serious the individual’s psychiatric diagnosis, the more difficult it is for him or her to abstain from drugs of abuse” (Ritsher, Moos, & Finney, as cited in Doweiko, 2006, p. 292).
- Van Wormer and Davis’s research show that the following disorders and disabilities commonly co-exist with alcoholism/addiction:
- Pathological (Compulsive) gambling
- Eating disorders
- Mood disorders
- Personality disorders
- Psychotic disorders
Doweiko (2006, p. 292) is more specific about the scope of the problem; in a Table showing “The overlap between substance use disorders and various psychiatric disorders”, they compare the “Lifetime prevalence of psychiatric diagnosis” with “Substance-use disorder”:
|Bipolar affective disorder (or manic depression)||64%|
|Antisocial personality disorder||84%|
|Attention deficit hyperactivity disorder (ADHD)||23%|
|Somatoform disorders||Unknown, but suspected to be related|
Many people with mental illnesses use alcohol and substances to “self-medicate” emotional pain and to relieve depression symptoms. Research studies on co-morbidity have found that “the individual’s alcohol abuse frequently precedes clinical manifestations of the person’s psychiatric condition” (Doweiko, 2006, p. 293). Meuser, Drake, and Wallach (as cited in Van Wormer & Davis) disagree with Doweiko when they stated, “Persons with co-existing disorders appear to use alcohol and other drugs for the same reasons persons without co-existing disorders use substances, i.e., loneliness, anxiety, boredom, and insomnia” (2003, p. 250).
- There are several hypotheses, with some evidence for each as to why psychiatric illness and substance dependence may co-exist. These, according to GreenFacts (2006) are:
- There may be a similar neurobiological basis to both
- Substance use may help to alleviate some of the symptoms of the psychiatric illness or the side effects of medication
- Substance use may precipitate psychiatric illnesses or lead to biological changes that have common elements with psychiatric illnesses
“It is interesting that the effects of many psychoactive substances can produce psychiatric-like syndromes. For example amphetamines and cocaine can induce psychotic-like symptoms. Hallucinogenic substances can produce hallucinations, which are an aspect of some psychoses. Furthermore, psychoactive substances regularly alter mood states, producing either euphoric and happy feelings, or inducing depressive symptoms, especially during substance withdrawal. Psychoactive substances can alter cognitive functioning, which is also a core feature of many mental illnesses. These factors all suggest common neurobiological substrates to both mental illnesses and substance dependence” (GreenFacts, 2006).
Treatment and recovery of co-morbidity: alcoholism/addiction with psychiatric illness
- Where co-morbidity – alcoholism/addiction with psychiatric illness exists, both conditions have to be treated simultaneously by appropriate professionals, utilising a multidisciplinary or integrated approach:
- Alcoholism and drug addiction should be treated by an addiction counsellor (preferably in an addiction treatment setting)
- Psychiatric illness should be treated by a psychiatrist
- The addiction counsellor and psychiatrist should liaise and work together regarding appropriate in-patient or out-patient treatment for the client
- The addiction counsellor and psychiatrist should refer where necessary to other professionals such as psychologists, social workers, dieticians, occupational therapists, general practitioners and biokineticists
- Specific interventions should be instituted where necessary, for example, grief counselling, cognitive behavioural therapy (CBT), couple counselling, nutritional planning, social/lifestyle assistance and physical wellness programmes
A welcome trend is for psychiatric clinics to have Dual Diagnosis Units (DDU). One such clinic’s website explains that “The DDU, while holding onto the belief that addiction is a disease in and of itself, also understands that the abuse of substances is associated with psychiatric diagnoses such as depression, anxiety and bipolar disorder. Addiction can also be related to unresolved issues from the past, current social circumstances and personality” (Crescent Clinic: Private Psychiatric Clinic, 2011).
The ideological conflict of identifying a primary problem has, to some extent been relieved with the “integrated” approach – which provides simultaneous treatment for clients’ needs. Instead of an abstinence approach, which is often unrealistic, harm-reduction therapy and motivational interviewing (MI) have proved useful in addiction treatment. “Abstinence is now considered a more realistic long-term goal for many, instead of being a rigid requirement for receiving treatment” (Von Wormer & Davis, 2003, p. 248). Newer approaches emphasise clients’ strengths, self-determination and harm reduction.
However in conclusion on the topic: Co-morbidity – alcoholism/addiction with psychiatric illness, I agree with Teggin (as cited in Hutton, 2011, p. 87), “Psychiatric treatment is usually long-term, in some cases life-long. Sobriety (or being clean) is essential for satisfactory psychiatric outcome and long-tem support from Alcoholics Anonymous or similar support systems is required”.
Crescent Clinic: Private Psychiatric Clinic. (2011). The Dual Diagnosis Unit (DDU). Retrieved September 30, 2011, from http://www.crescentclinic.co.za/The_Dual_Diagnosis_Program.html
Doweiko, H. E. (2006). Concepts of chemical dependency (6th ed.). Belmont, CA: Thomson Brooks/Cole.
GreenFacts. (2006). Why do drug addiction and mental illness often coexist? Retrieved October 27, 2011, from http://www.greenfacts.org/en/psychoactive-drugs/1-3/5-drugs-depression.htm
Hutton, B. (2011). Recovery RSA: A resource book for those affected by addiction. Johannesburg, South Africa: Stonebridge Books.
Van Wormer, K., & Davis, D.R. (2003). Addiction treatment: A strengths perspective. Pacific Grove, CA: Brooks/Cole – Thomson Learning.
World Health Organization. (2011). Mental health. Retrieved September 30, 2011, from http://www.who.int/topics/mental_health/en/