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Dual Diagnosis Resource

Dual Diagnosis Resource

Co-occurring Disorders and Dual Diagnosis Learn How Mental Disorders Tie into Addiction

Not only is it a tall order to face a legitimate mental health disorder, but many of these individuals struggle with substance use and put themselves at risk of addiction. Drinking or casual drug use is a common way for these individuals to try to self-medicate their mental health symptoms, and soon enough, addiction may rear its ugly head.

Substance use disorders include both abuse of and dependence on substances. A person who struggles with a substance use disorder as well as a mental health condition is said to have co-occurring disorders, also known as a dual diagnosis.

Use this resource to educate yourself about common co-occurring disorders, their close connection to addiction, and to see what the treatment process consists of for dual diagnosis patients.

Harmony Place

According to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH) (PDF | 3.4 MB), approximately 7.9 million adults in the United States had co-occurring disorders in 2014.

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Understanding Addiction

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Understanding Addiction Co-occurring Disorders: What Are They?

Mental illness can make routine tasks difficult, and it lowers the overall quality of life for the sufferer – and even his or her surrounding family. Mental health disorders that typically accompany substance use disorder include mood disorders, anxiety disorders and more serious thought disorders.

There are more than 200 distinct psychiatric disorders under the umbrella of “mental illness.” Only in the last few decades has the medical community started to understand and empathize with mental health issues. Society has come along even more slowly. People with legitimate mental health issues have historically suffered in silence, until recently.

Common Mental Disorders that Co-occur with Addiction

Among the 200-plus psychiatric disorders, these are the ones most associated with co-occurring substance use disorder:

  • Anxiety disorders
    • Panic disorder
    • Post-traumatic stress disorder (PTSD)
    • Social anxiety disorder
    • Generalized anxiety disorder (GAD)
    • Obsessive-compulsive disorder (OCD)
    • Phobias
  • Mood disorders
    • Major depressive disorder (MDD)
    • Dysthymia
    • Bipolar disorder
    • Adjustment disorder
    • Seasonal affective disorder (SAD)
  • Psychotic disorders
    • Schizophrenia
    • Dissociative disorders
  • Eating disorders
    • Binge eating
  • Impulse control disorders
    • ADHD
    • Compulsive sexual behavior
  • Personality disorder
    • Borderline personality disorder (BPD)
    • Narcissistic personality disorder (NPD)

Spotting the Signs and Symptoms of Mental Illness

Do you suspect that your friend, spouse, child or other loved one may be struggling with mental illness? The symptoms differ by disorder, of course, but here are some general signs to look for:

  • Strong feelings of anger and other noticeable mood swings
  • Frequent confused thinking
  • Excessive anxieties and fears
  • Frequent or excessive substance use
  • Numerous unexplained physical ailments
  • Suicidal hints or threats of harming oneself or others
  • Sudden social withdrawal
  • Struggling to cope with daily issues and tasks
  • Dramatic changes in sleeping or eating habits

When you start noticing several of the warning signs, make note of it and attempt to answer these questions:

  • When did you first notice the symptoms?
  • Is the person taking any new medications?
  • Are they going through a major life change?
  • Have they recently experienced a traumatic event?

Having answers to these questions will certainly help if you enlist the assistance of a health care provider down the road. Do not hesitate to call 911 if you or someone you love ever experiences a serious mental health crisis. 

Co-occurring Disorders: Who Has It?

Mental health disorders affect nearly every corner of society, but you will especially find them among those currently struggling with drug or alcohol abuse. Individuals with a family history of mental illness are also at a greater risk of developing the same or a similar disorder.

Almost everybody experiences symptoms of anxiety and depression from time to time, but the difference in those who have one of these mental health disorders is that they experience severe symptoms regularly – to the point where it impacts quality of life.

Mental Health Statistics

If you’re trying to size up mental illness, here are a few national and international stats worth paying attention to:

  • Around 40 million Americans aged 18 and older struggle with an anxiety disorder within a given year, according to the National Institute of Mental Health.
  • Roughly 15 million American adults suffer from social anxiety disorder.
  • Depression afflicts more than 10 percent of the world’s population.
  • More than 16 million American adults reportedly suffered a major depressive episode in 2015.
  • Personality disorders affect more than 9 percent of the U.S. population
  • PTSD impacts more than 7 million Americans adults.
  • More than 30 percent of Americans who have a legitimate mental health disorder also struggle with substance abuse.
  • Nearly 40 percent of alcoholics have a diagnosable mental health disorder.
Treating Dual Diagnosis

How Are Co-occurring Disorders Treated?

Working with dual diagnosis clients can be challenging, and some treatment centers won’t even attempt to try to accommodate such clients. Others claim to offer mental health treatment, but truly lack the resources to address all of the client’s issues and needs properly.

The difficulty in treating co-occurring disorders stems from the symptoms of drug and alcohol use often getting confused with symptoms of mental illness. In many cases, the client used drugs or alcohol to self-medicate his or her symptoms of mental illness

Drugs and alcohol interfere with the efficacy of medications prescribed for the treatment of mental health disorders, and some individuals fail to deal with their substance use because they attribute their symptoms purely to their mental health disorder.

If you struggle with substance abuse and you’ve already been diagnosed with a mental disorder or you suspect you may have one, it’s important to look for a rehabilitation center that offers dual diagnosis treatment. Long-term treatment (90 days or more) is also recommended.

How Harmony Place Treats Co-occurring Disorders

Since people who are seeking treatment for addiction are often struggling with mental health issues as well, Harmony Place remains committed to comprehensive, holistic treatment. This means we treat the whole person – mind, body and spirit – rather than just the symptoms and after-effects of addiction.

The Harmony Place team is qualified to screen for any undiagnosed and untreated mental health issues that may exist, and then we customize clients’ treatment plans accordingly. By addressing co-occurring disorders during the client’s time in rehab, they will have a much better chance of succeeding in recovery.

Clients in our residential program get to meet with their primary therapist three times each week. Our therapists come to understand each mental health disorder, and they offer tips on how to manage these symptoms going forward.

Our professional therapists also use a number of evidence-based techniques that help with mental health symptoms. These techniques include:

  • Cognitive behavioral therapy (CBT)
  • Dialectical behavior therapy (DBT)
  • Eye movement desensitization and reprocessing (EMDR)
  • Psychodrama psychotherapys
  • Motivational enhancement therapy (MET)

Clients also participate in psychoeducational groups at Harmony Place. In these sessions, our therapists educate about addiction and co-occurring disorders. We also utilize relapse prevention strategies along with distress tolerance, emotion regulation skills and interpersonal effectiveness as the means to help regulate emotions, impulses and behaviors in recovery.

Harmony Place has a distinguished team of wellness coordinators on staff 24/7 that is trained and experienced in working with individuals whose success depends upon dual diagnosis care.

See Our Dual Diagnosis Program

Your illness does not define you.
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Mental Health

Signs of Substance Abuse

Signs of substance abuse include reduced function at work, at school, in social relationships and worsening medical conditions. Substance abuse advances to dependence when the negative consequences associated with substance use increase, and the individual loses the ability control their substance use. Acquisition and use of substances take precedence over other activities. Dependence is accompanied by tolerance (needing more to achieve the desired effect) and withdrawal (physical and emotional symptoms that surface when a substance is reduced or removed).

Common Mental Health Disorders

Mental health disorders that typically accompany substance use disorders include mood disorders, anxiety disorders and more serious thought disorders. Major Depression, Bipolar Disorders, and Dysthymia are some of the more common mood disorders, and severe thought disorders such as schizoaffective disorder and schizophrenia may also be present. Individuals also frequently present with anxiety-related problems including PTSD, generalized anxiety, social anxiety, or panic disorders.

Treating substance use and mental health disorders and examining how they intersect is paramount for achieving successful treatment outcomes.

Adjustment Disorders

Symptoms of adjustment disorders can look very similar to symptoms of mood disorders or anxiety-related disorders. The distinguishing features are the presence of an identifiable major life stressor, symptoms, and effects on the person’s ability to function.

The DSM-5 Criteria for Adjustment Disorders includes:

  • Emotional or behavioral symptoms within three months of an identifiable stressor
  • Experience of stress is disproportionate to the normal expected response to a stressful life event
  • Cause notable distress or impairment in function
  • Symptoms are not an escalation of existing mental health disorder
  • The response is not better accounted for by normal bereavement
  • Once stressor is removed or the person begins to cope, the symptoms abate within six months

Anxiety Disorders

Anxiety Disorders

Anxiety is an emotion everyone is familiar with, as it is inherent in many parts of life. It becomes a disorder, however, when the anxiety does not dissipate and in fact worsens over time, eventually interfering with daily functioning.

Types of anxiety are differentiated by a variety of qualifiers.

Generalized Anxiety Disorder

Generalized anxiety disorder presents as excessive anxiety or worry for months at a time. It requires on-going assessment to differentiate Generalized Anxiety Disorder (GAD) from Post-Acute Withdrawal Syndrome (PAWS).
Generalized anxiety disorder (GAD) symptoms include:

  • Restlessness, feeling wound-up or on edge
  • Easily fatigued
  • Difficulty concentrating or the mind going blank
  • Irritability
  • Muscle tension
  • Difficulty controlling the worry
  • Sleep disturbance (difficulty falling or staying asleep, or fitful, unsatisfying sleep)

Panic Disorder

Different from generalized anxiety, panic disorder is expressed through recurrent, unexpected panic attacks. These are sudden periods of penetrating fear that may include heart palpitations, sweating, tremors or shaking, shortness of breath, and feelings of impending doom.
Panic disorder symptoms include:

  • Sudden and recurrent attacks of intense fear
  • Feelings of being out of control
  • Intense worries anticipating the onset of the next attack
  • Fear or avoidance of places or situations where panic attacks were previously experienced

Social Anxiety Disorder

Social anxiety disorder (aka social phobia) manifests as a notable fear in social or performance situations. The person predicts they will feel humiliated, criticized, rejected, or is afraid they will offend others.
Social anxiety disorder symptoms include:

  • Excessive anxiety about being with other people and difficulty talking to them
  • Feeling awkward and insecure around other people and worrying about feeling or being humiliated, embarrassed, rejected by, or fearful of offending others
  • Feeling fear of judgment or criticism by other people
  • Worrying for days or weeks preceding attendance at an event where other people will be gathered
  • Avoiding crowded places
  • Difficulty making friends or maintaining friendships
  • Experience blushing, sweating, or tremors around people
  • Feeling nauseous when in the presence of people

Attention-Deficit Hyperactivity Disorder

Attention-Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a mental health disorder characterized by abnormal levels of hyperactive and impulsive behaviors. People who suffer from ADHD tend to have a hard time staying focused or sitting still for extended periods of time. While this disorder tends to be diagnosed in children, it can also be diagnosed as an adult.

There are three main types of ADHD. They are:

  • Predominantly hyperactivity-impulsive
  • Predominantly inattentive
  • Combination of both

Predominantly Hyperactive-Impulsive

Those suffering from this type of attention-deficit hyperactivity disorder tend to have impulsive and hyperactive traits. They might constantly interrupt someone when they are talking or be constantly fidgety. While it’s not as common with this type of ADHD, those suffering from predominantly hyperactive-impulsive ADHD may still find it difficult to focus at times.

Predominantly Inattentive

Unlike someone suffering from the previous type of ADHD, this person is likely to have a severe problem when it comes to focusing. They often struggle with certain functions and processes such as finishing tasks, focusing, and even following basic instructions. This type of ADHD is most common among girls. 

A Combination of Both

The majority of people who are diagnosed with ADHD tend to show signs of both of the two types of ADHD. They likely have trouble focusing while also being hyperactive.

Bipolar Disorder

Bipolar Disorder

Bipolar disorder is a brain disorder distinguished by severe mood swings including mania or hypomania (emotional highs) and depression (emotional lows). In a depressed phase, the individual may feel sad or hopeless and lose interest or pleasure in activities that were previously interesting or pleasurable. In a hypomanic (less intense than mania) or manic phase, the individual may experience increased energy, feel euphoric, or unusually irritable.

The fluctuation between moods can have a notable impact on sleep, energy, activity, judgment, behavior, and the ability to complete daily tasks.

There are four types of bipolar disorder, and each produces abnormal changes in mood.

Bipolar I Disorder

Bipolar I Disorder is differentiated by an episode of manic symptoms that last at least seven days or are so severe as to warrant hospitalization. The abnormal state can be extreme elation, high energy, expansive, or irritable mood, and this mania can trigger a psychotic episode. While an episode of depression is not required to diagnose Bipolar I, usually the individual will experience depressive episodes as well. The depressive episodes typically last at least two weeks. It is also possible to experience both symptoms of depression and mania concurrently, known as a mixed episode.

Bipolar II Disorder

Individuals diagnosed with Bipolar II Disorder have experienced at least one major depressive episode and at least one hypomanic episode. They have never had a full-scale manic episode or mixed episode, however.

Cyclothymic Disorder

Cyclothymic disorder, or cyclothymia, is characterized by multiple periods of hypomanic symptoms as well as multiple periods of depressive symptoms that last for at least two years (one year in children and adolescents). The hypomanic or depressive symptoms do not meet the criteria for a hypomanic or major depressive episode. The individual may be asymptomatic for brief periods, but the duration is less than two months at a time.

Bipolar Disorder, Other Specified or Unspecified Bipolar

This designation is for individuals who do not meet the criteria for Bipolar I Disorder, Bipolar II Disorder, or Cyclothymic Disorder. Still, the individual experiences clinically significant changes in mood.



Codependency is a term that was first attributed to spouses of alcoholics, but it was learned that the identifiable characteristics are prevalent in the broader population as well. Codependency is a dysfunctional pattern of emotional and behavioral features that impact one’s ability to enjoy healthy relationships with others. It can be considered a one-sided, dysfunctional relationship where one person subordinates their own needs to the attention and care of another. It may also be a trait acquired through mirroring the dysfunctional patterns in the family.

Codependency patterns can be found in caretakers of ill or elderly, as well as individuals in relationships suffering from mental or chronic illnesses. When applied to addictions, it is a behavior that enables the addict to continue to fly under the radar of responsibility and continue irresponsible addictive behaviors. Further, addicts/alcoholics in committed relationships with other substance users may find themselves struggling in their primary relationships.

Codependent traits include:

Low self-esteem

Self-esteem is eroded through countless attempts and failures to rescue an individual with a substance use disorder. Over time, one feels increased guilt and shame for being inadequate or unlovable enough to deter the substance user from continued substance use and the associated consequences.


Substance users can be manipulative about getting what they want in order to support their ongoing alcohol and/or drug use. Codependents frequently acquiesce and accommodate those requests, pleas, or demands. They avoid saying “no” because they do not want to rock the boat. They fear being abandoned, so they concede to the needs of the substance user. The addict/alcoholic may convince the codependent that failure to meet their needs will cause the addict/alcoholic to use more. The codependent ends up subordinating their own needs to accommodate substance users.

Poor boundaries

Boundaries are both physical and emotional. They differentiate where you stop and another person starts, and can pose significant problems for the codependent person. If their boundaries are permeable, they are more susceptible to experiencing what the addict/alcoholic is feeling. Those feelings may be distorted from addiction, but the codependent feels them at the same intensity as the addict/alcoholic, regardless if those feelings are rational or justified. Conversely, codependents may possess rigid boundaries. They exercise a sort of emotional cut-off, making it hard for others to connect to them. Vacillation between diffuse and rigid boundaries often sends mixed messages and can create discord in relationships.


Typically, individuals with healthy boundaries can hear different points of view. They may agree or disagree. They allow for varying opinions without feeling threatened or dismissed. There is room for more than one opinion. Poor boundaries yield negative consequences. As stated, when a person is flooded by the emotions of the substance user, that person experiences the same intensity as the addict/alcoholic. There may not be a rationale for the emotion and, absent logic, the codependent reacts. They may passionately defend the person or become passionately defensive, if they reject sentiment. They often experience unrelenting feelings of anger.


Poor boundaries also lead the codependent to work hard to problem solve or rescue the addict/alcoholic. In the case of substance use, when their efforts fail, they try harder. The codependent will make excuses for the addict/alcoholic so they do not have to experience the consequences of their addictions. They will put the addict/alcoholic’s needs ahead of their own. Even when it comes to treatment, they will search high and low for the path of least resistance for the addict/alcoholic. They continue to do this even when that person does not want help, and this rejection of help fuels the already depleted self-esteem of the codependent.


The life of the addict/alcoholic is tumultuous. Poor boundaries open the floodgates, and the codependent is inundated with the chaos of addiction. In response, then they strive for control to provide a sense of consistency and safety. A certain amount of containment and control in life is expected and necessary. Codependents take control to an extreme at times. They can become wound very tight and they lose the ability to be flexible or share their feelings. Without adaptive coping strategies to deal with the stress imposed upon them, the codependents may resort to the same dysfunctional coping behaviors of the people they seek to rescue. They may use substances to regulate emotional states. They may throw themselves into work and other commitments to avoid dealing with the addict/alcoholic. To control a situation, the codependent’s caretaking, people-pleasing, and poor boundaries can violate the boundaries of others. The other persons may react or retaliate and the codependent feels even more rejection. This can result in the very thing they set out to avoid – loss of control.


Codependent persons fear rejection or abandonment. Even the most accomplished person requires validation from others to feel okay about themselves. Often, they are intolerant of being alone and they go to any length to maintain their relationship with the addict/alcoholic. The inability to end the relationship imprisons them not only by the confines of their own codependency, but in the painful and emotionally abusive dance of addiction they engage in with the addict/alcoholic.


To maintain focus on the problems of the addict/alcoholic, the codependent cannot face that they have their own incapacitating disorder. Denial, a psychological defense structure, protects them from acknowledging or dealing with their own issues. Left untreated, it gets worse. They attribute all problems to the addict/alcoholic or associated situations. The worse the problem becomes, the more they object or persist in trying to fix it. Either way, they avoid addressing their own vulnerability and need for love or intimacy.

Problems with intimacy

Intimacy, or a close, affectionate familiar relationship, can strike fear in the codependent person. Fear of criticism, rejection, or shame creates problems for the codependent. Low self-esteem and diffuse boundaries exacerbate these problems. If the codependent is also a substance user, they may hide their struggle with intimacy behind their substance use. Conversely, they may also fear being smothered by a relationship and reject the need for attachment, instead exercising their autonomy and independence.

Depressive Disorders

Depressive Disorders

Depressive disorders should not be confused with “the blues,” nor are they sad moods that one can easily dismiss or “get over.” The hallmark of a depressive disorder is the persistent feelings of sadness or worthlessness, with a loss of interest in things that used to bring the person pleasure.

A depressive disorder is a mental illness that affects the individual physically, emotionally and cognitively. Left untreated, the symptoms can last for long periods and cause varying degrees of impairment in daily tasks. The good news is that research shows that most people with depressive disorders respond well to medication, therapy or a combination of both.

Signs & Symptoms of Depressive Disorders:
  • Persistent depressed mood – as evidenced by feelings of sadness, hopelessness or purposelessness
  • Misplaced guilt or feelings of excessive worthlessness nearly every day
  • Loss of pleasure or interest in activities or hobbies that used to be enjoyable
  • Disproportionate reactions to minor concerns with irritability, frustration or angry outbursts
  • Feelings of fatigue or low energy almost every day
  • Significant changes in weight
  • Notable changes in appetite
  • Psychomotor retardation (such as moving or talking slowly) as observed by others
  • Psychomotor agitation (such as feeling restless or difficulty sitting still)
  • Diminished ability to think, focus, recall or make decisions
  • Difficulty sleeping, awakening early or oversleeping
  • Thoughts of death or suicide, or suicide attempts

Depressive Disorder Classifications:

Major Depressive Disorder

Major depression manifests when five or more of these symptoms are present minimally for two consecutive weeks. Either depressed mood or loss of pleasure must be included in the symptoms, and they must cause notable impairment in functioning, meaning that they interfere with the ability to work, sleep, eat, and enjoy once pleasurable activities. Episode(s) of depression cannot be otherwise attributed to other medical conditions or substance use.

Persistent Depressive Disorder

Otherwise known as dysthymia, persistent depressive disorder symptoms and intensity tend to ebb and flow over time. The symptoms must present for a period of two years for this diagnosis and they do not usually disappear for more than two consecutive months. Individuals with persistent depressive disorders may experience episodes of major depression along with less severe bouts of depressive symptoms.

Perinatal Depression

Perinatal depression is a major depressive episode that is experienced during pregnancy or following delivery (postpartum depression). It is more severe than the somewhat mild depressive and anxiety symptoms that women tend to experience within two weeks of delivery. This type of extreme dysphoria, anxiety, and exhaustion experienced concurrently with perinatal depression interferes with the new mother’s ability to care for their babies and/or themselves.

Psychotic Depression

The distinct feature of psychotic depression (major depressive disorder with psychotic features) is the presence of symptoms of psychosis in addition to acute depressive symptoms. Psychosis may be in the form of delusions and/or hallucinations. Delusions are unwavering, false beliefs that the individual clings to despite proof of the contrary, while hallucinations are perceptions of hearing sounds or seeing objects that are not actually present. In the instance of psychotic depression, the psychotic features are either mood-congruent or mood-incongruent. Mood-congruent psychotic features are those that are consistent with depression (i.e. guilt, inadequacy, and worthlessness), and mood-incongruent psychotic features indicate the hallucinations and/or delusions conflict with the depressed mood (i.e. laughing when sad).

Seasonal Affective Disorder

Seasonal affective disorder is type of depression that is influenced by the change in seasons. Normally, it has an onset at the same time every year and coincides with a specific season (winter or summer months). Typically, these depressive episodes correspond with winter months, but some people experience it in reverse, and the depressive symptoms are activated during the summer months. Individuals experiencing “winter depression” have symptoms that include low energy, hypersomnia, overeating, weight gain, social withdrawal, and cravings for carbohydrates. Symptoms more specific to summer depression include loss of appetite, sleep disturbance, weight loss, and anxiety.

Personality Disorders

Personality Disorders

A personality disorder is a long-term mental disorder. People who suffer from personality disorders tend to have a rigid and oftentimes unhealthy pattern of thinking, behaving, and functioning. They have trouble perceiving and relating to certain situations and people. Suffering from a personality disorder can be a debilitating disease and can often lead to significant problems when it comes to everyday life including work, school, social activities, and relationships. 

When it comes to personality disorders, they are typically grouped into 1 of 3 clusters. Many people who suffer from a personality disorder tend to show characteristics of at least one other type of personality disorder as well. Let’s take a look at the different types of personality disorders based on the cluster they fall into.

Cluster A

Those suffering from Cluster A personality disorders tend to show signs of eccentric or odd behavior. The following are considered Cluster A personality disorders:

Schizoid personality disorder – Individuals who suffer from a schizoid personality disorder often display detachment when it comes to relationships. Often, individuals with this disorder show little to no emotion. They will likely avoid forming any sort of close relationship and may typically prefer to be alone instead of being with other people.

Paranoid personality disorder – A person who suffers from a paranoid personality disorder will tend to be paranoid or suspicious constantly. The individual might even think that everyone is out to get them in some way. Those who have this personality disorder often have trouble trusting and confiding in other people. The disorder causes people to constantly assume that those around them are going to try and do harm to them in some way.

Schizotypal personality disorder – People with schizotypal personality disorders also tend to be very uncomfortable when it comes to forming close bonds and relationships. They might also have a distorted way of thinking and show signs of eccentric behavior. They also may display signs of odd behavior and beliefs and may even suffer from debilitating social anxiety.

Cluster B

Those suffering from Cluster B personality disorders often exhibit behaviors that might be seen as dramatic. They also tend to be very emotional and will likely behave and act unpredictably. The following are considered Cluster B personality disorders:

Borderline personality disorder – A person who has a borderline personality disorder may tend to show signs of intense emotion, poor self-image, and impulsivity. These behaviors can cause instability when it comes to relationships. An individual who is suffering from this disorder will likely go to great lengths to avoid being abandoned. They may experience ongoing feelings of emptiness, display inappropriate levels of anger, and in some cases even attempt suicide multiple times. 

Antisocial personality disorder – A person with an antisocial personality disorder might fail to understand the rules when it comes to social and societal norms. They may even lie or deceive others and even act impulsively.

Narcissistic personality disorder – Individuals who suffer from narcissistic personality disorders constantly feel the need to be admired and be the center of attention. They will likely show little to no empathy for others and will feel a constant sense of entitlement and self-importance. 

Histrionic personality disorder – Those who have histrionic personality disorders tend to be attention-seeking and can even be uncomfortable when they aren’t the center of attention.

Cluster C

Cluster C personality disorders are commonly characterized by feelings of anxiety and fearful thinking and behavior. The following are considered Cluster C personality disorders:

  • Obsessive-compulsive personality disorder – Not to be confused with obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorders may cause people to seem to be obsessed with things that most people consider trivial. Sometimes, these obsessions may even exist and persist to a detrimental level. Individuals may focus on having control over everything, even if that control is unattainable. 
  • Dependent personality disorder – People who suffer from a dependent personality disorder may be “clingy”, having a constant need to be cared for and looked after. These individuals often have a difficult time making decisions without receiving validation or reassurance from someone else. 

Avoidant personality disorder – Those who suffer from an avoidant personality disorder often suffer from extreme shyness. They may even feel inadequate and be extremely sensitive to any type of criticism. Individuals living with an avoidant personality disorder will tend to avoid people unless they are completely sure that others will like them.

Process Addictions

Process Addictions

Addiction can manifest itself in other ways besides drug or alcohol abuse. During treatment, absent the primary substance of abuse, it is not unusual for other addictive behaviors to surface. At Harmony Place, we work with clients to identify such behaviors. We endeavor to guide our clients towards recovery from all addictive behaviors.

Process Addictions are repetitive behaviors sometimes referred to as “behavior addictions.” In the short-term, some behaviors provide a “reward”, and survival is dependent upon certain rewards. For example, eating and sex are biological processes that are pleasurable, so the reward is the impetus for reproduction and survival of the species.

Current evidence reveals that behavior addictions possess features that resemble those of substance addictions. These behavior addictions serve to provide the same type of immediate gratification that is derived from substance use. They both provide rewards that will incentivize individuals to repeat the behavior or activity despite any negative consequences that follow or that interfere with day-to-day living.

Behavior addictions may initiate with feelings of tension or excitement before performing the behavior and a feeling of pleasure or relief when the behavior is completed. Over time, the behavior addiction, like substance dependence, becomes more compulsive and less pleasurable. Afterward, individuals typically experience guilt or regret for their actions. At this point, the behavior is acted out to avoid any negative effects (i.e. reduce anxiety or quiet obsessions).

Disordered Eating

Disordered Eating refers to problematic eating behaviors. Disordered eating behaviors can include some of the patterns exhibited with the more severe eating disorders, such as restricting, binging, purging, or dieting. Eating disorders, for our purposes, are considered more extreme, can be life-threatening, and require specialized treatment. Disordered eating behaviors include a distorted blend of eating habits, beliefs about food, dieting behaviors, and body image disparities.

In food addiction, also known as compulsive overeating or binge eating, certain foods interfere with our feelings of satiety, prompting us to keep eating long after we’re full. About 3 percent of the population has a food addiction, with women affected at least twice as frequently as men.

Certain foods (namely those rich in fat and sugar) affect the pleasure centers of the brain. Much like the addictive drugs cocaine or heroin, neurotransmitters in the brain tend to be activated by certain foods that trigger the “reward” of increased dopamine. Once the individual learns that certain foods boost the feelings of reward, they may be compelled to eat more. In contrast, normal food consumption is regulated and the individual eats when hungry and stops when full.

Signals of disordered eating include:

  • Using food to avoid feelings
  • Low self-esteem
  • Negative effects on health
  • Poor body image
  • Restricting food intake
  • Craving food even when you feel full
  • Eating when you are no longer hungry
  • Justify eating behaviors

Gambling Addiction

An estimated 2 million Americans are compulsive gamblers, while 4 million to 6 million people are problem gamblers. Compulsive gambling, also known as pathological gambling, is an uncontrollable urge to wager on games of chance or “skill,” despite severe financial, social and legal consequences. Gambling addiction is a type of impulse control disorder.

Gambling crosses the boundary into and addiction when the individual:

  • Begins betting more frequently
  • Places more money on the bet than they intended
  • Becomes agitated and aggressive over gambling losses
  • Is preoccupied with gambling activities
  • Bets greater sums to make up for losses

By the time the individual seeks treatment, they typically have taken a huge financial hit. They may be struggling with unemployment, loss of family, house, and/or legal problems. Having lost everything, it is not unusual for such individuals to contemplate or attempt suicide. Stabilization during the crisis event is a necessary step for a positive outcome.

Sex Addiction

Sex addiction involves an unending obsession with sexual fantasies and behavior. The act of sex, or having an orgasm, is not necessarily the driving force for the sex addict. While there are gender differences in the expression of sex addictions, like other addicts, sex addicts endeavor to sustain the “pleasure state” of the sexual fantasy whenever possible. The act of sex or eventual orgasm ends the pleasure state and the sex addict then returns to routine life, which is what they are trying to avoid in the first place.

Sex addiction affects an estimated 18 million to 24 million Americans, or about 6 to 8 percent of the population. About a third of all sex addicts are women, and about two-thirds are men.

The behaviors of male sex addicts are characterized by objectifying their companions, minimal emotional attachment, and acting out in familiar and identifiable sexual patterns. Female sex addicts, on the other hand, tend to perceive their sexual compulsions in romantic terms. Their sexual behaviors, however, are as void of intimacy as their male counterparts. The addictive sexual behaviors of both men and women persist in the face of severely negative consequences.

Regardless of their gender, sex addicts are unable to control their sexual proclivities and acting out behaviors, which are exhibited by:

  • Compulsive masturbation
  • Frequent visits to adult bookstores, strip clubs or other sexually provocative environments
  • Multiple affairs and/or brief successive relationships
  • Engaging in prostitution (either servicing or procuring)
  • Participation in sexual activities without consideration of potential consequences
  • Frequently participating in casual sex with people contacted through the internet or in person
  • Regularly engaging in unprotected sex practices
  • Exhibitionism, voyeurism, solicitation resulting in misdemeanor offenses

Gaming Addiction

Addiction to video games, which is a subset of Internet addiction, is a type of compulsive disorder. Gaming addiction affects roughly 3 million young people between the ages of 8 and 18, as well as a significant number of adults. Males more often become addicted to gaming than do females, and males are more likely to be addicted to games promoting social aggression.

Common devices that can lead to video game addiction are:

  • Computers
  • Smartphones and handheld devices
  • Dedicated consoles
  • Arcade machines


Occasional shopping sprees should not be confused with a shopping addiction, also known as compulsive buying disorder. Some characteristics of a shopping addiction include:

  • Hiding credit card statements, shopping bags, or store receipts
  • Confessing to shopping, but withholding details about the amount spent
  • Spending more than they can afford
  • Shopping to mask feelings
  • Continuing to shop even though it is negatively impacting relationships

Women are only slightly more prone to compulsive buying than are men are. In both genders, the act of buying produces a “shopper’s high” similar to the euphoria brought on by drugs or alcohol. An estimated 20 million Americans have a shopping addiction.

Shopping addictions tend to create significant financial problems for the individual and their family when overwhelming debt drives a wedge in their relationships. It is a serious condition and culminates in feelings of guilt and shame, which can aggravate substance use by activating the urge to bury those feelings. Loss of control of compulsive spending habits can lead to financial, emotional, and relational disaster.

PTSD and Trauma

PTSD and Trauma

Trauma is a distress response or emotional state that results from exposure to serious emotional stressors or physical injury. Combat, natural disasters, car accidents, or sexual assault are examples of life-threatening or life-ending events considered to be traumatic. Not everyone is exposed to potential fatal or injurious events, however. Experiencing devastating, dangerous, or terrifying events can also trigger a trauma response. The sudden unforeseen death of loved one can also prompt an acute stress response.

Most people who experience a traumatic incident have short-term difficulty adapting and coping with the effects of the trauma. They do not escape unscathed, though. After exposure to a traumatic event, shock or disbelief are expected to follow. However, most individuals recover from the experience of the traumatic stressor naturally with time, support, and self-care.

When the trauma response symptoms last more than one month and cause clinically significant impairment in social or occupational functioning, the criteria for Post-Traumatic Stress Disorder (PTSD) have been met. PTSD is a psychological disorder that can surface following a traumatic event.

Symptoms of PTSD present within three months of the traumatic experience. The distinguishing features of a PTSD diagnosis include:

Exposure to threat or actual event, directly or indirectly

  • Direct exposure
  • Witnessing the trauma
  • Indirect – learning a relative or close friend experienced trauma, or was a victim of a fatality that was violent or unexpected
  • Indirect exposure to aversive aspects associated to a traumatic incident, typically relating to professional duties (e.g. first responders)

Intrusion or Re-experiencing

  • Intrusive thoughts or memories
  • Traumatic nightmares
  • Flashbacks
  • Emotional distress in response to trauma reminders
  • Physical reactivity following exposure to reminders of traumatic event


  • Avoiding thoughts or feelings connected to the traumatic event
  • Avoiding any stimulating trauma-related people or activities

Negative thoughts or feelings that begin or worsen following trauma

  • Inability to recall important details about the trauma
  • Excessively negative thoughts and beliefs about oneself or the world
  • Persistent blame of oneself or others for the traumatic experience
  • Negative emotions
  • Severely diminished interest in activities
  • Feeling alienated
  • Inability to experience positive feelings

Increased arousal and reactivity

  • Difficulty concentrating
  • Irritability or aggression
  • Sleep disturbance
  • Hypervigilance
  • Exaggerated startle response
  • High risk or destructive behaviors

Other features

  • Symptoms last for more than one month
  • Symptoms cause clinically significant impairment in social or occupational functioning
  • Symptoms are not due to medication, substance use, or other illness

Frequently Asked Questions

Co-occurring Disorders Frequently Asked Questions

Do you have any additional questions about this complex subject? See if we have your answer in the frequently asked questions below, or reach out to us directly if you have a more specific question.

Does the substance use disorder or the mental health disorder come first?

It truly depends on the person. Some people don’t show signs of mental illness until they begin repeatedly abusing substances. In order cases, as we mentioned, the substance use disorder developed amid a person’s futile attempt to self-medicate an existing mental disorder.

What’s worth keeping in mind is if someone has a genetic predisposition to mental illness, excessive or prolonged substance use will increase his or her risk of developing a specific mental disorder.

What are the common signs of anxiety?

Anxiety is an emotion everyone is familiar with, as it is inherent in many parts of life. It becomes a disorder, however, when the anxiety does not dissipate and actually worsens over time, eventually interfering with daily functioning.

The type of anxiety one may have depends on a variety of qualifiers.

Generalized anxiety disorder (GAD) symptoms include:

  • Restlessness, feeling wound-up or on edge
  • Easily fatigued
  • Difficulty concentrating or the mind going blank
  • Irritability
  • Muscle tension
  • Difficulty controlling one’s worries
  • Sleep disturbance (difficulty falling or staying asleep; or fitful, unsatisfying sleep)

Panic disorder symptoms include:

  • Sudden and recurrent attacks of intense fear
  • Feelings of being out of control
  • Intense worries anticipating the onset of the next attack
  • Fear or avoidance of places or situations where panic attacks previously occurred

Social anxiety disorder (aka social phobia) symptoms include:

  • Excessive anxiety about being around other people, and difficulty talking to them
  • Feeling awkward and insecure around other people and worrying about feeling or being humiliated, embarrassed or fearful of offending others
  • Excessive fear of judgment or criticism by other people
  • Worrying for days or weeks preceding attendance at an event where other people will be gathered
  • Avoiding crowded places
  • Difficulty making friends or maintaining friendships
  • Experience blushing, sweating or tremors around people

How does someone overcome social anxiety to go to treatment?

You’re struggling with drug and alcohol addiction and you’re aware that it’s a problem. The signs of addiction have grown too obvious to ignore. You know that you cannot stop drinking and using on your own. You’re going to need the professional guidance of a treatment program to detox and address the underlying issues which might be contributing to your addiction, as well as learn new ways of living where you won’t feel like you need to drink or use.

While some people aren’t aware that they have underlying issues or even co-occurring issues, you are. The thought of treatment sounds awful to you because of all the people that will be there. You know they are likely going to encourage you to speak up in group therapy sessions and attend 12-step meetings where there are lots of other people, too. What nobody seems to understand is that you feel you have to drink and use in order to be around other people. You struggle with social anxiety disorder and it can be overwhelming.

Unfortunately, drugs and alcohol don’t really work, at least, not permanently. The more you abuse them, the more you need them, and the less you are able to stand any of the symptoms of your social anxiety without them. To work through your social anxiety disorder to go to treatment, you’re going to have to go to treatment to work out your social anxiety disorder.
Dual diagnoses of anxiety and substance use disorders are common. Anxiety, and all of the disorders included under its umbrella, such as social anxiety disorder, is the most common mental illness affecting adults in the United States.

Where to Start

One of the quickest, scientifically proven ways to start dealing with your anxiety is accepting that you are anxious. Acceptance is a major theme in recovery. Accepting doesn’t mean you condone or even like the fact that you have social anxiety disorder. Accepting means you realize there’s nothing you can do about it – and that the ways you’ve been trying to control it aren’t working anymore.

In a professional rehabilitation facility, you will learn to manage your social anxiety in a healthy, regulated way. Through dual diagnosis residential treatment programs like the one at Harmony Place, you can receive holistic treatment for both social anxiety and substance use disorder, helping you heal at the mind, body and spirit levels.

What are the signs of obsessive-compulsive disorder?

Obsessive-compulsive disorder commonly co-occurs with substance use disorder. Turning to drugs and alcohol is a typical attempt to cope with difficult thoughts and urges in OCD. However, addiction can be obsessive and compulsive in its own way, exacerbating preexisting OCD symptoms.

Here are some of the signs to observe in those who may be struggling with OCD:

Obsessive About Cleanliness and Germs

Using hand sanitizer repetitively, needing to clean all of the time, feeling anxious and distressed about the presence of germs – these can become obsessions which lead to chronic compulsive behaviors. OCD sufferers cannot stand to have anything dirty or unorderly, and are terrified of germs.
The root of this behavior is often heartbreaking. OCD can stem from trauma – trauma which made a “clean” life feel “dirty” and threatened.

Compulsive Checking and Re-Checking

If you can’t leave the house without checking the lights four times, the windows five times, and the gas in the oven six times, you might be struggling with OCD. Checking and rechecking isn’t a matter of paranoia, but a matter of survival.

If there isn’t a constant checking and rechecking, the worst could happen as a result. Fear of not being in control stems from trauma and life experiences in which control was taken away.

Sexual Impulses

OCD can manifest through sexual impulses and obsessive thoughts. Instead of matters of control like cleanliness, organization and checking, thoughts become sexually involved. Leading to compulsive sexual desires, OCD can often cause trouble in someone’s life through inappropriate sexual behaviors.

Obsessive Thought, Compulsive Action

The examples listed above are just some of the most popular forms of obsessive and compulsive behaviors. However, as all mental illnesses go, OCD can manifest in unique ways, depending on each individual. If you experience obsessive, unwanted and intrusive thinking on a regular basis followed by uncontrollable compulsive behaviors, you might be struggling with obsessive-compulsive disorder.

What are some of the signs of narcissism?

Narcissism isn’t always out loud. Sometimes, it’s hidden within quirky behaviors you can’t help but notice, yet wouldn’t notice…if they weren’t so noticeable. That’s the subtle tactic of narcissism; being a narcissist isn’t an end game. With treatment and therapy, it is possible to discover the root of narcissism and to build healthy habits to counteract harmful behaviors.

Five of the more overlooked signs of narcissism include:

Small Offenses Make You Really Upset

When someone doesn’t answer you right away, do what you wanted them to do, meet your needs, says something inconsiderate, or does any other little thing to offend you, you get upset. You don’t just get upset, you get really upset. Angry, resentful and betrayed, a narcissist will either react in a puff of ego and superiority or totally break down into a vulnerable inferiority state.

You’re Not Entitled! It’s Just the Way It Should Be

Obviously, when you ask for something, it should just be done. Why wouldn’t it be? You asked for it! If it can’t get done right away, then you expect whomever you’ve asked to find another way to get it done. It isn’t that you’re entitled and expect everything for nothing. You’re actually convinced it’s up to other people to serve your happiness to you on a silver platter. You can’t accept anything less because you don’t know how to make yourself happy.

Being Wrong Doesn’t Work for You

Agree to disagree? Not so much. When it comes to arguments, you have to win. Narcissists who find themselves in leadership positions often aren’t able to admit when they have made a mistake or when someone else is doing better than they are. You want to be the best and be right all the time. Sadly, this stems from a deeply rooted insecurity that you aren’t good enough at all.

The Sun Is Your Only Competition

That is, for being the center of the universe. One of the ways you receive that desperately needed validation is through making yourself the center of attention as often as possible, either in large and loud ways or subtle and silent ways. If someone else should get more attention than you for something, it won’t last long.

You’re Super Selfless

Giving back is big for you because you give back big. Donations? Happy to post about it on Facebook. Volunteering time? Taking a selfie. In a conversation about community service? Watch out, here comes your list. You’re so selfless that you are lucky you have anything left to give. Thankfully, you have a lot.

Do mannequins contribute to poor body image?

Though they are supposed to mimic the human body for displaying clothes that will be worn on real human bodies, mannequins seem to be anything but realistic. Research suggests that mannequins may have more of an effect than being a blatant misrepresentation of the human body. The unrealistic thinness most mannequins in fashion shops have could be hurting body image in many people.

For the average female mannequin, the represented body size is equal to a woman who would be categorized as severely underweight. However, when it comes to male mannequins, only a small percentage represent what would be considered an unhealthy weight in males, according to a University of Liverpool study.

Emphasizing extreme thinness as part of the mainstream ideology regarding body image and body size is a major contributing factor to low self-esteem and poor body image. It’s also associated with part of the obsessive thinking in eating disorders.

Getting rid of extremely thin mannequins won’t be the solution to the overall problem of body image. Our culture as a whole needs to move past the idea that thinness is perfection, and that perfection is even real. Each individual has a specific genetic makeup that gives their body healthy limitations.

Fighting Back Against the Unhealthy Perception

Around the world, countries have taken measures to fight against the unrealistic ideals of body image. Israel, for example, requires that all media that has been digitally altered display a stamp letting people know it isn’t an authentic image. France has banned fashion runway models who have a BMI below the country’s health standard. Other countries that are involved in major fashion events are starting to take similar actions.

How can binge eaters cope during the Holidays?

Binge eating disorder is a compulsive eating disorder in which an individual loses their ability to regulate their eating. Characterized by uncontrollable binge episodes, an individual with binge eating disorder experiences guilt and shame regarding their eating. They feel unable to change their patterns and experience total powerlessness over their hunger and eating habits.

The holiday season has become associated with gluttony. For someone suffering a mental health disorder specifically regarding uncontrollable eating, the gluttonous holiday season can be hard. Rather than find their limit at the end of a meal, they find themselves in a state of depression or guilt. Instead of starting back on a regular balanced routine the next day or even that same night, they will continue to indulge.

Here are some tips to help you through the holiday season if you are working on recovering from a binge eating disorder:

Maintain a System of Support

If you are in treatment, continue to stay in contact with your staff, therapist and eating disorder specialist or counselor. Call any sponsors or recovery peers regularly for support. If your family is safe and supportive for you, find a family member whom you can rely on to listen to you when you’re experiencing triggers. Avoid family members who will shame you or criticize your eating.

Don’t Binge and Purge

Binge eating disorder and other eating disorders such as bulimia are not the same. Binge eating disorder usually isn’t characterized by purging. However, a common holiday feast tradition is to fast the entire day before the meal so that one can eat more. For those with binge eating disorder, this is a dangerous practice.

Make sure to stick to your nutrition plan, eating well-balanced meals and snacks before the holiday meal. Though it may be hard to resist temptation, you will be grateful not to end the holiday with the sense of guilt that follows a binge episode.

Why do people with bipolar disorder often stop taking their medication?

Approximately 40 percent of all people diagnosed with bipolar disorder are affected by specific biological damages which inhibit their decision to take their medication. For people with bipolar disorder, which is categorized by shifting moods of mania and depression, not taking medication can lead to severe consequences. Moods become more erratic, coping with moods becomes more challenging, and the moods themselves become more extreme.

People with bipolar disorder fluctuate from low periods of depression to heightened periods of mania. The constant switching of moods leaves an impact on the brain, which could lead to the decision not to continue taking medication. Research suggests that the specific parts of the brain that are affected by bipolar disorder may not be able to recognize the importance of taking medication.

This impairment has a scientific name: anosognosia. This specific disorder is exclusive to people with mental illness and happens most frequently in people with bipolar disorder or schizophrenia. Called “impaired awareness of illness,” this condition creates a block between the reality of the illness one has – bipolar disorder – and the recognition of needing to take medication.

Refusing to take medication is common in episodes of mania in which someone feels so good and so heightened that they believe they will never be depressed again, and therefore do not have to take medication. Convinced they have “snapped out of it” or didn’t have a problem to begin with, these individuals abruptly stop taking their medication and refuse to take it anymore.

Not taking medication for bipolar disorder is possible if the person builds a comprehensive skill set for managing emotions. Still, a combination of therapy and medication is recommended in most situations. With the support of medications, one can learn to live with bipolar disorder in a sustainable way.

How does Harmony help with mental disorders after residential treatment?

After a client graduates our 30-day residential program, the treatment continues to stay customized and the mental health disorder addressed as he or she progresses through our outpatient program.

Our discharge planning can also connect the individual to a mental health professional and other helpful resources in his or her hometown once the rehab period has concluded. So if you come into Harmony Place with an undiagnosed mental disorder, not only will we treat it here, but we will help you find a new provider who will help you manage this disorder once you return home.

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