AA and Dual Diagnosis: Addressing Mental Health Issues

A young mother worries about her children to the point of daily panic attacks. (“What if he falls out of the crib at night? What if that paint is toxic? What if ...?) Her anxiety has crossed the line of what’s normal for “new mother” concerns — but so has her drinking.

A police officer relives the domestic violence incident he witnessed with flashbacks throughout the day and nightmares when he tries to sleep. He’s also become a regular at the neighborhood bar where he goes to get relief.

A college freshman struggles to stay focused in her large lecture-hall classes and keep up with assignments. Frustrated and on her own for the first time, her drinking is no longer just a weekend thing.

These three people have something in common: they show symptoms of alcohol misuse along with co-occurring disorders — anxiety, post-traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD). Let’s explore what dual-diagnosis treatment is all about and why 12-step programs such as Alcoholics Anonymous (AA) might not be enough to address their concerns. 

Mental Health and Addiction: AUD and Beyond

Alcohol use disorder (AUD) is a mental health disorder marked by an inability to stop drinking despite alcohol’s negative effects on our lives. When we’re caught in the grips of AUD, all aspects of our lives are affected: our health suffers, our relationships become strained, our performance at work or school declines. And yet, we can’t stop drinking.

While an outside observer might wonder, “Why can’t they just quit?” AUD is more complicated and more common than many people realize. In fact, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), as many as 28.8 million adults in America suffered from AUD in 2021. That’s over 11% of adults aged 18 or older! Picture a subway car with 50 people on board. Chances are, at least five (or more) have had AUD in the past or are currently struggling.

When Troubles Team Up

While modern science has made AUD recovery more possible (more on that later), sometimes life throws us for an extra loop. Many of those struggling with AUD have another co-occurring disorder that complicates the picture and makes recovery more challenging. Here are the most common co-occurring disorders, according to the Substance Abuse and Mental Health Services Administration (SAMHSA):

• Anxiety and mood disorders. We all get worried sometimes. But when that worry gets in the way of our life and leads to panic attacks, chronic stress, and insomnia, we might be looking at a mental health condition known as generalized anxiety disorder (GAD).
• Eating disorders. More than a “diet gone wrong,” eating disorders such as anorexia and bulimia affect our relationship with food in ways that threaten our health. While anorexia is all about food restriction, bulimia involves binging and using compensatory behaviors (such as purging or exercise) as a counteractive measure. Binge eating disorder (BED), in turn, involves eating large amounts of food in episodes characterized by loss of control. 
• Schizophrenia. Marked by thoughts and perceptions that don’t match reality, schizophrenia is a severe mental health condition that affects how we feel and behave.
• Bipolar disorder. Life with bipolar disorder is an emotional roller coaster: we might feel full of energy and euphoric one day only to wake up to a deep low the next.
• Major depressive disorder. Life isn’t always sunshine and rainbows, and we’re all bound to feel sad at times. However, major depressive disorder (MDD) goes beyond the occasional low mood and is marked by persistent hopelessness, a lack of interest in previously enjoyable activities, and a sadness that doesn’t seem to lift. 
• Conduct disorders. While conduct disorder is typically diagnosed during childhood, it can affect adults as well. Conduct disorders involve a pattern of disruptive and violent behaviors and difficulties following rules. The areas of the brain in charge of impulse control are compromised, leading to rash and sometimes dangerous decisions.
• Post-traumatic stress disorder. Sometimes a traumatic event we experience — whether it’s active combat or a bad breakup — follows us for weeks, months, or even years on end, causing flashbacks and haunting our dreams. PTSD is often characterized by severe anxiety and makes daily life difficult.
• Attention deficit hyperactivity disorder. Just as depression is more than a bout of the blues, ADHD goes beyond spacing out mid-conversation every once in a while. Characterized by persistent patterns of inattention, hyperactivity, and impulsivity, this condition makes it difficult to focus and control our impulses.

While all these mental health conditions can “team up” with AUD, some are more frequent than others, with anxiety, depression, and PTSD topping the list. However, the relationship between alcohol misuse and co-occurring disorders is often difficult to untangle. Let’s take a closer look at why.

The Puzzle of Cause and Effect

Determining which came first — AUD or other co-occurring disorders — can be a bit of a chicken-and-egg problem. Here’s why, according to NIAAA:

• Preexisting psychiatric conditions make AUD more likely. For example, schizophrenia and bipolar disorder are known risk factors for AUD. Likewise, our anxiety or PTSD symptoms might drive us to misuse alcohol in an attempt to temporarily calm the mental storm.
• Drinking can also serve as a trigger for some psychiatric conditions. This link is especially true for those who start drinking in adolescence because the brain isn’t fully developed yet.
• AUD and co-occurring disorders share similar risk factors. For example, adverse childhood experiences (ACEs) or traumatic events can trigger PTSD or anxiety disorder while also serving as a catalyst for alcohol misuse.
• Co-occurring disorders make diagnosis more difficult. This increased difficulty in diagnosis can lead to treatment delays. Given that many symptoms of AUD overlap with those of other mental health disorders, diagnosis is often difficult. For example, sleep disturbances, dysphoria, and mood swings are common in many conditions we’ve mentioned so far. No wonder it can be hard to tell which came first! 
• AUD and co-occurring disorders tend to fuel each other. For example, if we’re struggling with PTSD, we might be more likely to use alcohol to cope, even though it only adds to the problem in the long run. No matter which came first, they can act as a tag team, increasing harms to our health in an ever-worsening cycle.

Now that we see why AUD and co-occurring disorders can cause extra trouble together, let’s take a look at the brain changes that come with them. Understanding the neuroscience behind dual diagnosis is the first step in finding the right course of treatment!

The Neuroscience Behind Dual Diagnosis

AUD and other mental health issues affect our brain chemistry, often exacerbating each other. Here’s how alcohol affects the brain and how other conditions play into these effects:

• Our reward circuits get hijacked. Alcohol wreaks havoc on our reward circuits by boosting dopamine — the “feel-good” neurotransmitter involved in learning and habit formation. At the beginning, the boost of pleasure from dopamine release gets us hooked. However, as dependence sets in and the brain scales back natural dopamine production, we find ourselves drinking just to feel “normal” and stave off the rebound depression and anxiety that set in when the effects wear off.


  
  When it comes to other mental health conditions, dopamine imbalance often comes with the territory. For example, ADHD has been linked with lower dopamine levels — a feature that makes alcohol all the more appealing as a temporary “solution.” Likewise, dopamine dysregulation is a feature of bipolar disorder, playing a key role in the transition between depressive and manic episodes. Dopamine is also affected in schizophrenia, with theories suggesting both dopaminergic hyperactivity (too much dopamine) and hypoactivity (not enough dopamine) in different brain regions.
• Other neurotransmitters are out of balance. In addition to boosting dopamine, alcohol increases levels of GABA, an inhibitory neurotransmitter, as it puts the breaks on glutamate, its excitatory counterpart. GABA and glutamate dysregulation also has been linked to anxiety and depression, as well as to bipolar disorder and schizophrenia.
• Our prefrontal cortex gets impaired. The prefrontal cortex — the part of the brain in charge of reason and higher-order thinking — takes a back seat when alcohol is in the picture. As a result, our inhibitions loosen up, and we’re more prone to risky behavior (going home with a stranger or driving on the wrong side of the street might seem like good ideas!). 


  
  In a similar way, conduct disorder, as well as manic episodes in bipolar disorder, involve prefrontal cortex deficiencies and can lead to hasty decisions we might regret later. 
• The amygdala gets “louder.” At the same time, the amygdala — the area of the brain that deals with emotions — is not kept in check by the prefrontal cortex when we drink. As a result, we might experience mood swings (much as we do if we’re struggling with bipolar disorder, anxiety, or depression). Schizophrenia, in turn, is associated with abnormal patterns of activation and deactivation in the amygdala, while conduct disorder is linked to reduced amygdala activity that leads to characteristic problems with empathy and consideration of others’ feelings.
• Our stress response is amped up. Individuals with dual diagnosis often have an overactive stress response. The hypothalamus-pituitary-adrenal (HPA) axis becomes dysregulated, leading to heightened stress and anxiety, which can trigger substance use as a coping mechanism. Likewise, anxiety, PTSD, and the manic phase of bipolar disorder are associated with higher cortisol levels — the hallmark feature of the stress response.
• We get stuck in “default mode.” Habits such as alcohol misuse activate the so-called default mode network (DMN), which is the brain circuitry associated with rumination, self-referential thoughts, and addictions. Likewise, ADHD has been associated with faulty top-down controls between the prefrontal cortex and the DMN.

For more information about co-occurring disorders, check out “Where To Find Help for Mental Health Issues Related to Alcohol Use” as well as “The Positive Impacts of Sobriety on Mental Health: Reduced Anxiety, Depression, and Improved Emotional Well-Being.” For now, let’s turn our attention to why 12-step programs may not be the answer to dual-diagnosis treatment and which alternatives offer a science-based approach.

AA and Dual Diagnosis: Exploring the Limitations

Those of us who struggle with alcohol may be pointed towards Alcoholics Anonymous (AA) at some point in our journey. After all, this peer-led support program has been around for almost a century!  While it has benefits, it’s not for everyone — particularly for those with a dual diagnosis. Here’s why:

• AA is focused on alcohol. It’s no surprise that Alcoholics Anonymous focuses on, well, alcohol. While some members’ stories might speak to co-occurring disorders, the main focus is our relationship with alcohol.
• It might not be emotionally supportive enough. Although there’s plenty of support to be found in AA and other 12-step programs, the support tends to come from the sense of community, not diagnostic or healthcare support. Also, alcoholism continues to be presented as a “character defect,” as it was in the fellowship’s early days in the 1930s. Neuroscience doesn’t come into the picture.
• It lacks the medical resources we might need. Back in the day, AA tended to be actively anti-psychiatry and against any treatment that involved medications. While times have changed, AA is still not the place where we can find resources if we’re struggling with a psychiatric disorder (such as schizophrenia) that might require medical treatment.
• It has a one-size-fits-all approach. AA offers the same program for everyone, centering on the 12 Steps that we “work” with a sponsor. Those of us who require a more personalized treatment plan — especially someone with AUD and a co-occurring mental health disorder — are advised to turn to specialized professionals.

While AA does have benefits, when it comes to addressing co-occurring disorders, it’s lacking. That’s where science comes in!

Dual Diagnosis Treatment: Science to the Rescue

So if AA isn’t the solution to co-occurring disorders, what is? Let’s look at some science-based strategies that can help.

1. Medication-Assisted Treatment (MAT)

Sometimes a neurochemical imbalance calls for a medical solution. These days, psychiatric medications have improved and can be tailored to our individual needs. And while the decision to go this route is always a personal one, it’s something to consider, especially if our condition is known to benefit from medication-assisted treatment (MAT). For example, antipsychotic medications are often used to treat schizophrenia, while mood stabilizers, antipsychotics, and antidepressants can help even out the highs and lows of bipolar disorder.

As for AUD, there are options for MAT as well! While some reduce alcohol’s psychoactive effects, others act as deterrents by causing unpleasant reactions when mixed with booze or by targeting the root of the problem by reducing cravings. (To learn more, check out “Which Medications Work Best To Help Me Stop Drinking?”)

2. Therapy 

Just as medical treatment has improved over the years, therapy has grown by leaps and bounds. It’s no longer all about recalling your dreams or childhood memories (though that can be part of the picture if it helps). Here’s an overview of various forms of therapy and how they can work wonders for AUD and co-occurring disorders:

• Cognitive behavioral therapy (CBT) helps us reframe our thoughts. The technique of disclosing cognitive distortions and shifting our thinking in a way that aligns with reality can work wonders for AUD as well as for many co-occurring mental health disorders. (Want to learn more? Take a look at “How Can Cognitive Behavioral Therapy (CBT) Help With Alcohol Misuse?”)
• Dialectical behavior therapy (DBT) is all about finding balance. Developed originally as treatment for bipolar disorder, DBT has now been used to treat AUD and other mental health conditions. Its core modules of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance help us deal with life’s ups and downs while maintaining inner peace. (Check out “How Can Dialectical Behavior Therapy (DBT) Help With Alcohol Misuse?” for more information.)
• Interpersonal therapy focuses on building healthy relationships. It can help those with conduct disorder and anxiety-related disorders overcome barriers related to social situations.
• EMDR therapy helps us work through trauma. Eye movement desensitization and reprocessing, or EMDR, is especially useful for PTSD, but has also been applied to AUD, anxiety, and depression when trauma is part of the overall picture. 
• Motivational enhancement therapy builds our desire to change. Motivational coaching works wonders for building our motivation to make healthy changes in our life. It can also enhance other treatments.
• Mindfulness-based therapy reduces stress. Mindfulness practices reduce activity in the amygdala and increase prefrontal cortex function, enhancing emotional regulation and reducing stress. (To learn more, check out “Can Mindfulness Techniques Relieve Anxiety?”)

As we can see, the world of therapy has expanded since the days of Freud and his famous couch. It’s time to explore what it can do for our dual-diagnosis treatment journey!

Summing Up

While the dual diagnosis road can be a challenging one, rest assured there’s light at the end of the tunnel! With science at our side, we’re more capable than ever of addressing the complex needs that come with co-occurring disorders.

In the end, many of us find that tackling multiple mental health challenges leaves us better equipped to tackle future obstacles in our path. Seeing the broader context of co-occurring disorders and the neuroscience behind mental health issues calls for a more comprehensive toolbox that we can use for anything the future might throw at us.