Especially in the case where substance abuse and mental illness occur together, medical and psychological health professionals can find it challenging to figure out exactly what’s going on. These situations can be even harder to understand for the person or loved ones involved in or affected by the issue.
There are some consistent standards regarding diagnosis of addiction and mental health disorders that are relied on by mental health professionals to diagnose and treat these disorders, and to distinguish substance use disorders from other mental health issues. It can be reassuring for those dealing with a substance abuse or mental health disorder diagnosis to understand the process of observing and diagnosing these issues; in turn, this can make it easier to understand why certain treatment decisions are made, and to gain trust in and commitment to the treatment program.
How Are Addictions and Mental Health Disorders Diagnosed?
Various observations and tests are used to help professionals diagnose mental health disorders, including substance use disorders. In particular, over the course of nearly two centuries, one particular diagnostic guideline stands out, the Diagnostic and Statistical Manual of Mental Disorders, also known as DSM-5.
What is in DSM-5?
DSM-5 is a detailed guideline to mental health disorders and their symptoms and manifestations, which is used as a standard for diagnosing these illnesses and determining appropriate treatment. Originally established by the American Psychiatric Association (APA) and contributed to by research from a large number of global health organizations, this manual is considered to be the main authority on psychological disorders in the US.
History and Updates
A predecessor of DSM was first published by the APA more than 170 years ago, in 1844. At the time, it was little more than a census tool used to note and classify the types of mental illnesses that were being observed in patients in mental hospitals and institutions. As time went on, it was used to gather and standardize mental health statistics across mental health institutions.
It was in the early 20th century that this document first began to be used for diagnostic purposes as well as classification. The classifications were also broadened after World War II through information provided by the U.S. Army.
After World War II, the DSM was created based on a similar document that the World Health Organization (WHO) was using. At this point, the information was intended to be used more as a diagnostic system – still classifying the conditions, but using the classifications and the growing understanding of mental health to begin to diagnose mental illness and determine how to treat it.
Over the next several decades, APA revised the manual and created a few revisions. Then, in 2000, APA began the 13-year process of creating the most recent revision, working in concert and collaboration with WHO. Released in 2013, DSM-5 is used as the current standard for diagnosing mental health disorders and determining treatment.
Who Manages and Updates DSM-5?
APA is the main body that manages the revisions of the DSM. However, the current revision of the manual was contributed to by 400 participants from 39 countries. Through a series of conferences, these global representatives reviewed research from around the world and reported to APA and WHO regarding the most current knowledge on mental health. This was then used to determine the categories and information that should be included in the manual.
What Information Is Covered?
DSM-5 includes three general categories of information. These are the:
- Diagnostic classification: This is the listing of all the disorders that are recognized by the experts who compiled the manual.
- Criteria sets: This includes the symptoms that must be present in order for the disorder to be diagnosed by a psychiatric medical professional.
- Descriptive text: This includes a variety of information on the disorder, including other disorders that may look the same, how common the disorder is, what consequences the disorder may have on the person who has been diagnosed, tests to help determine whether the criteria have been met, and other relevant information.
Are There Other Authorities on Diagnosing Mental Illness?
Over nearly the same time that APA was developing the DSM, WHO was developing a similar manual that covered all types of diseases. This manual, called the International Classification of Diseases, or ICD, is used in concert with DSM-5 to classify levels of psychiatric disorders.
A completely different type of diagnostic system is being developed by the National Institutes of Mental Health. Called the RDoC, which is short for Research Domain Criteria. This system includes many more levels of information in the diagnostic model for mental illness. These additional forms of information include genomics, brain biology information, and other biological markers, along with the traditional behavioral and physiological symptoms, that some research has shown can more definitively diagnose mental health disorders.
RDoC is still being developed. While it may prove to be a solid tool for diagnosis, DSM-5 is still the most commonly used standard.
Tests for Diagnosing Mental Illness and/or Addiction
Unlike physical illness, there are no laboratory tests to diagnose mental illness at this point. As a result, mental health disorders, including substance use disorders, are diagnosed using self-reporting by the person being diagnosed and the doctor’s observations of the person’s behavior or attitudes. This is done through interviews, questionnaires, and other methods that are then compared to the criteria listed in DSM-5.
These diagnostic tools, along with the doctor’s experience and observation, can help determine the condition and potential treatment. Nevertheless, it is important for both the medical professional and the person who is dealing with the symptoms to be flexible, because some symptoms may indicate a number of potential conditions.
According to DSM-5, alcoholism and other alcohol use problems, such as binge drinking, are all classified as alcohol use disorders. These disorders are diagnosed using a series of 11 criteria that are measured through self-reporting by the person who is being diagnosed. If the person has met two or more of the 11 criteria in the last 12 months, an alcohol use disorder is diagnosed. The criteria include (but are not limited to):
- Drinking more or longer than intended on an occasion
- Wanting to stop drinking but being unable to
- Being unable to focus on anything else due to a strong desire to drink
- Finding that drinking or being sick from drinking interferes with responsibilities or pastimes
- Taking excessive risks due to drinking (driving drunk, engaging in other dangerous activities, etc.)
- Having physical symptoms if drinking is stopped, such as trembling, nausea, racing heart, or seizures
A person who has two or three of these symptoms is considered to have a mild alcohol use disorder. For those with four or five symptoms, the diagnosis is moderate. Six or more symptoms indicate a severe alcohol use disorder, which can indicate alcoholism or extreme alcohol abuse.
If the person does not volunteer information about alcohol use and habits, the doctor or psychiatrist may pay attention to behaviors, attitudes, and other symptoms to help determine whether alcohol may be a factor in the person’s symptoms. An obvious observation may be that the person has the smell of alcohol on the breath. A less obvious symptom may be the person having a low ability to focus or a lack of balance. People who are trained to recognize these types of symptoms can make a deduction about whether alcoholism may be a factor, and apply diagnostic questions from DSM-5 to verify the deduction.
Determining Whether Drug Addiction or Abuse Is Present
In DSM-5, alcohol abuse and various forms of drug abuse are all classified under a single, overarching category called substance use disorder. The criteria for determining drug addiction or abuse are the same as for alcohol abuse, as described above.
The added dimension in diagnosing these disorders depends on the professional gathering further information on both the person’s status and history, and the doctor’s experienced observations of the person’s behavior and attitude. These, in combination with DSM-5 criteria, can present a convincing diagnosis of drug abuse or addiction. The tests and information can include:
- Laboratory tests: These can determine whether or not the person has drugs in their system. Urine tests and blood tests can help determine what the substances are.
- Family history: If a person has a family history of substance abuse, the person is more likely to have a substance use disorder as well.
- Previous diagnoses of substance abuse: People who have had substance use disorders are more likely to have additional or continuing drug abuse or addiction issues.
- Physical symptoms: Certain drugs cause physical symptoms that can indicate abuse of the substance, such as restlessness in someone using cocaine or an inability to concentrate in someone using heroin.
There is no precise recipe for diagnosing these sorts of disorders. However, medical and psychiatric professionals can combine this information and observations to determine whether a substance use disorder is present.
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Confirming or Ruling out Mental Health Disorders
When a person visits a doctor with a concern about having some sort of mental health disorder, the existence of any alcohol or drug abuse influencing the symptoms is unlikely to be volunteered by the person. For example, when a person sees a doctor regarding potential depression or other mood disorders, it is unlikely alcohol use will be brought up by the person in the discussion. For this reason, it is important for the doctor or psychiatrist to be able to distinguish between symptoms of mental health disorders that may be caused by alcohol use, and symptoms of a mental health disorder that exists independent of alcohol use.
This can be challenging, because often symptoms of substance abuse and symptoms of mental health disorders are not only similar, but also intertwined after a period of time. Whether the substance use disorder existed first or the mental health disorder did, there comes a point where they may influence one another to the degree that treatment for one cannot have a positive outcome without treating the other as well.
Tests or methods that can help the treatment professional make this distinction include conversations with the person that can flesh out the history of symptoms before, during, and after initiation of alcohol use and development of abuse. It is also helpful for the medical professional to talk with family, friends, and coworkers or employers of the person to get a better idea of what symptoms occurred first and when substance abuse began in relation to the symptoms. The doctor should focus on the point that the person began to exhibit signs of addiction, rather than the point at which the substance use began.
Using the diagnostic criteria in DSM-5 can help with some of this diagnosis. What may not be obvious to a layperson may be something that a doctor or psychiatrist will specifically look for to help in determining the true cause of symptoms. The main factor to determine is whether the mental health disorder came before or after the substance abuse.
- About 20.2 million adults or about 4 percent of the US population had substance use disorders in 2014.
- Only about 5 million people received the specialized substance abuse treatment they needed in 2014.
- According to the National Institute of Mental Health, approximately 1 percent of people in the US reported having some kind of mental health disorder during 2014.
- About 1 percent of the US adult population had a severe mental disorder in 2014.
- Anxiety disorders are the most common, occurring in about 18.1 percent of the population in a given year and 28.8 percent of the population over a lifetime.
- Various estimates show that between 35 and 54 percent of people with some form of severe mental illness go untreated.
- More than 3 percent of all adults, or 9 million people, had a co-occurring mental health disorder and substance use disorder in 2014. For 1 percent of adults, the co-occurring mental health disorder was considered severe.
- What does real depression look like?
- Are there varying degrees of anxiety disorder?
- Do all cases of mental health disorders require treatment?
- What should people do if they suspect mental illness?
- What’s the difference between bipolar and depression?
- Are phobias legitimate mental health concerns?
- How to screen for post-traumatic stress disorder (PTSD)?
- Is drug addiction a mental health disorder?
- Who can properly test for mental illness?
- How difficult is it to diagnose co-occurring disorders?
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WHAT DOES REAL DEPRESSION LOOK LIKE?
Sometimes, the only way to tell the difference between a true depression disorder and one caused by substance abuse or addiction is to know which one came first. If the symptoms of depression came before the alcoholism occurred, then it is likely that the person suffers from true depression.
An easy way to tell is to see if the person’s symptoms of depression continue after detox and treatment for the substance abuse issue. If this happens, the person’s depression was likely caused by the addiction.
However, the idea of “real” depression can be deceptive. It is a good idea to note that some types of substance abuse can result in changes in brain chemistry that may make depression persist for long periods of time. As an example, people who struggle with benzodiazepine addiction (anti-anxiety medications) and withdrawal can develop true major depressive disorder that requires treatment with antidepressants.
ARE THERE VARYING DEGREES OF ANXIETY DISORDER?
There are a number of levels of anxiety disorders. Some people who are dealing with anxiety may be able to control the fears that manifest from this disorder to a degree and continue typical functioning at work, school, and home. On the other hand, some may experience anxiety to a degree that is detrimental to the person’s ability to function on a daily basis.
Generally, children and youths all exhibit some level of anxiety, ranging from mild symptoms that resolve quickly to severely debilitating fears that inhibit the person’s ability to engage in behaviors that are typical for the person’s age and social development. The degree to which this manifests can predict the continuation of the anxiety disorder into adulthood.
Left untreated, a minor anxiety disorder can become a major issue if it inhibits the person’s ability to keep up with responsibilities at work, school, or home. For this reason, even a minor anxiety problem should be referred to a professional for assessment and treatment.
DO ALL CASES OF MENTAL HEALTH DISORDERS REQUIRE TREATMENT?
While mild symptoms of a mental health disorder may seem easy to dismiss, there can be a risk in leaving mental health disorders untreated. Without diagnosis and therapy, some mental health disorders can continue to develop into more complex disorders that impede the person’s ability to function. In addition, some mental health disorders can trigger further issues such as substance abuse.
For this reason, even a minor disorder that begins to disrupt a person’s ability to meet responsibilities or participate in activities that were previously enjoyed should be analyzed for treatment by a mental health professional. This can help prevent the development of further problems later on.
WHAT SHOULD PEOPLE DO IF THEY SUSPECT MENTAL ILLNESS?
If a person suspects a mental health disorder, it is prudent to seek out a certified mental health professional to provide assessment, diagnosis, and, if necessary, treatment. It can sometimes be difficult for the individual to determine the risks and future development of the mental illness; getting a mental health expert to analyze and determine the extent of the condition and to provide treatment can help to avoid complications later on.
It is important to avoid self-diagnosis and self-treatment, particularly in the form of self-medication. The ability to properly diagnose mental illness requires training and experience, and even then it can be a challenge, as described above. Also, because forms of self-medication can often lead to substance use disorders, self-diagnosis can actually complicate the problem. For this reason, a suspected mental illness should always be referred to a medical or psychological professional for analysis and treatment.
WHAT’S THE DIFFERENCE BETWEEN BIPOLAR DISORDER AND JUST BEING DEPRESSED?
Bipolar disorder includes symptoms of depression, but it also involves periods of a condition called mania, in which the person displays some or all of the following symptoms:
- Suddenly inflated self-esteem
- Decreased sleep
- Excessive talking and racing thoughts
- Distraction or fluctuating attention
- Atypical drive toward a specific goal
- Excessive desire for or involvement in highly pleasurable activities
A manic episode is generally considered to involve three or more of these symptoms. If manic episodes occur alternately with depressive periods, the person is more likely to have bipolar disorder rather than just depression.
ARE PHOBIAS LEGITIMATE MENTAL HEALTH CONCERNS?
Phobias can easily disrupt a person’s ability to function in day-to-day activities. Because of this and based on the fact that even minor mental health issues, left untreated, can result in more severe issues later on, phobias should be considered as important as any other mental health concern.
An example can include a social phobia, also referred to as social anxiety. This sort of mental health disorder, left untreated, can impede a person’s ability to participate in enjoyed activities or fulfill responsibilities when the phobia is triggered. This, in turn, can potentially lead to self-medication with certain substances to minimize the symptoms, resulting in a later substance use disorder. Treating the phobia or anxiety problem before it reaches this point can prevent more severe problems later on.
HOW DOES A PROFESSIONAL SCREEN FOR POST-TRAUMATIC STRESS DISORDER (PTSD)?
There are a variety of tests that can screen for PTSD. These include tests like those recommended by the U.S. Department of Veteran Affairs, among other screenings. Generally, these screenings include assessments of:
- Exposure to a traumatic event
- Persistent intrusions of the event, as in nightmares or vivid memories
- Avoidance of related stimuli
- Anxiety levels in response to similar stimuli, including hypervigilance or easy startling
- Symptoms lasting longer than one month after the event
These are just some of the criteria involved in diagnosing PTSD. All of the criteria recommended by DSM-5 should be met in order to give this diagnosis.
IS DRUG ADDICTION A MENTAL HEALTH DISORDER?
Substance use disorder is a classification within DSM-5. The reason for this is that substance abuse and addiction create physical changes in the way the brain behaves that have an effect on mental health. In addition, substance use disorders have been shown to respond to psychiatric treatment and therapy.
Substance use disorders, like most mental health disorders, are chronic mental health conditions that require maintenance treatment throughout the life of the person who is diagnosed with this type of disorder.
WHO CAN PROPERLY TEST FOR MENTAL ILLNESS?
Psychiatrists, certified mental health and substance abuse practitioners with training specific to diagnosing mental illness, and other types of psychological and medical professionals who understand the diagnostic processes for mental health disorders can test for and diagnose mental illness, including substance use disorder.
Before obtaining a diagnosis, it is important for a person who suspects a potential mental health disorder to verify the credentials of the practitioner providing the diagnosis.
HOW DIFFICULT IS IT TO DIAGNOSE CO-OCCURRING DISORDERS?
Because symptoms of mental health disorders can resemble or result from substance use disorders, it can be very challenging to determine whether a person is dealing with a true co-occurring disorder or just symptoms resulting from the addiction. To help make this determination, a treatment professional can begin by treating the addiction or substance abuse. If the symptoms of the mental health disorder diminish, it is likely that it is not a separate disorder, but rather symptoms of the substance abuse.
It is prudent to note that substance use disorders sometimes cause physical changes in the body that result in mental health disorders, so it is still important to treat the co-occurring disorder to the degree possible to resolve the symptoms of both disorders. In true cases of co-occurring disorders, simultaneous treatment that addresses both disorders is recommended.