Drug Addition (Mood Disorders)

Mood Disorders + Substance Use Disorders (Dual Diagnosis)

Mood Disorders + Substance Use Disorders

• Mood disorders and substance use disorders strongly connected.

Dual diagnosis = having both:

• a mental disorder

• a substance use disorder

Main Stats

• About 30% of people with mood disorders also have a substance use disorder.

• This is more common in bipolar disorder than depressive disorder.

• Both mood disorders and substance use disorders often begin in late adolescence or early adulthood (Hard to tell which causes which)

Models of Comorbidity (4 models)

Models of Comorbidity

Comorbidity = when two disorders happen together.

1. Secondary Psychiatric Disorder Model

• Substance use disorder → mood disorder

• Substance use increases the risk of developing a mood disorder.

2. Secondary Substance Abuse Model

• Mood disorder → substance use disorder

• A mood disorder increases the risk of developing substance use problems.

• Example: someone may use substances to cope with depression or mania.

3. Bidirectional Model

• Substance use disorder ↔ mood disorder

• Each disorder can make the other worse.

• They may have different causes, but they influence each other.

4. Third Variable / Common Factor Model

• A shared factor causes both disorders.

• Example: genetics, trauma, stress, or brain chemistry may increase risk for both.

DSM-5: Substance Use (10 substances)

DSM-5: Substance Use and Addictive Disorders

1. Substance Use Disorders

The DSM-5 includes 10 substance classes:

• alcohol

• caffeine

• cannabis

• hallucinogens

• inhalants

• opioids

• sedatives

• stimulants

• tobacco

• other substances

These disorders can include:

• substance use disorders

• substance-induced disorders

  • intoxication

  • withdrawal

  • other substance-related problems

Addictive Disorders (1 main one)

2. Addictive Disorders

The main addictive disorder listed is:

• Gambling disorder

Substance Use Disorder — Clinical Features Diagnosis (9 Main symptoms)

Substance Use Disorder — Clinical Features Diagnosis

A person may be diagnosed with substance use disorder if they have at least 2 symptoms within 12 months.

Main Symptoms

• Taking more than intended

• Failing to cut down

• Spending lots of time getting, using, or recovering from the drug

• Cravings

• Drug use interferes with school, work, relationships, or hobbies

• Using in dangerous situations

• Continuing use even when it worsens physical or mental health

• Tolerance = needing more of the drug for the same effect

• Withdrawal = feeling bad when stopping or reducing use

Extra Categories

Substance problems can also be classified by:

• type of drug

• intoxication

• withdrawal

Example:

• opioid use disorder

• opioid intoxication

• opioid withdrawal

Substance Use Disorder Severity (3 Levels)

Severity Levels

• Mild: 2–3 symptoms

• Moderate: 4–5 symptoms

• Severe: 6+ symptoms

Main Idea

Substance use disorder is diagnosed based on how much drug use disrupts a person’s control, health, responsibilities, and daily life.

Drug Addiction

Drug Addiction

• Addiction is a chronic brain disease.

• It affects brain circuits involved in:

  • reward

  • motivation

  • memory

  • behavior control

What Happens in Addiction

Brain circuit problems can affect a person’s:

• biology

• thoughts/emotions

• behavior

• relationships

Addiction Is Characterized By

• difficulty stopping drug use

• poor control over behavior

• strong cravings

• not fully recognizing the harm being caused

• problems in relationships

• unhealthy emotional reactions

Addiction Cycle (3 Stages)

Addiction Cycle

Addiction can become a repeating cycle with 3 stages:

1. Binge / intoxication

   • using the drug and feeling its effects

2. Withdrawal / negative mood

   • feeling bad when not using

3. Preoccupation / anticipation

   • craving or thinking about using again

Main Idea

As drug use continues, the cycle becomes stronger and more intense, creating a spiral of distress.

Drug Addiction — Psychological Framework (2 Shifts)

Drug Addiction — Psychological Framework

Main Idea

As addiction gets worse, why someone uses the drug changes.

1. Positive Reinforcement → Negative Reinforcement

Early addiction:

• Person uses the drug because it feels good.

• This is positive reinforcement.

Later addiction:

• Person uses the drug to avoid feeling bad.

• This is negative reinforcement.

Simple version:
At first: “I use because it feels good.”
Later: “I use so I don’t feel awful.”

2. Impulsivity → Compulsivity

Early addiction:

• More impulsive

• Risky or poorly planned actions

• Driven by tension, excitement, or urges

Later addiction:

• More compulsive

• Repeated behavior even when harmful

• Driven by stress, anxiety, and feeling unable to stop

Main Takeaway

Addiction can shift from pleasure-seeking to relief-seeking, and from impulsive choices to compulsive behavior.

Biological Framework: Drugs of Abuse — Main Brain System and Pathways

Biological Framework: Drugs of Abuse

Main Brain System

Drugs of abuse affect the mesocorticolimbic dopamine system

Key pathway:

VTA → Nucleus Accumbens

• VTA = ventral tegmental area

• NAc = nucleus accumbens

What Drugs Do

• Most addictive drugs cause a fast increase in dopamine.

• Dopamine helps explain why drugs can become reinforcing and addictive.

Main Takeaway

Addictive drugs strongly activate the brain’s dopamine system, especially the VTA → nucleus accumbens pathway.

• This affects motivation, craving, and learning, which helps explain why addiction can develop.

Dopamine (Motivation & Learning)

Dopamine does not simply mean pleasure.

Dopamine is more about:

1. Motivation

• Makes you more likely to approach or seek something.

• Helps drive wanting/craving.

2. Learning

• Helps the brain learn what predicts rewards.

• Acts like a “teaching signal.”

How Dopamine Responds

Dopamine increases when:

• something unexpected and rewarding happens

• a cue predicts a reward

Dopamine changes when:

• an expected reward does not happen

Drug Addiction Adaptations

Drug Addiction Adaptations

• Addiction changes the brain over time.

• These changes are called neuroplastic alterations.

• 3 stages

Main Takeaway

Addiction is a cycle involving:

reward → withdrawal/stress → craving

Over time, different brain regions adapt, making drug use harder to control.

Drug Addiction Stage 1

1. Binge / Intoxication Stage

Main focus: reward and drug use

Involves:

• habits

• goal-directed actions

• reward-seeking

Brain areas:

• VTA

• nucleus accumbens

• basal ganglia

Drug Addiction Stage 2

2. Withdrawal Stage

Main focus: stress and negative emotions

Symptoms can include:

• uneasiness

• irritability

• stress

• anxiety

• negative mood

Brain areas:

• amygdala

• BNST

Drug Addiction Stage 3

3. Preoccupation / Anticipation Stage

Main focus: craving and self-control

Involves

• cravings

• decision-making problems

• poor self-control

• inability to resist urges

• memory problems

Brain areas:

• hippocampus

• prefrontal cortex

• amygdala

Drug Addiction — Diathesis-Stress Model

Drug Addiction — Diathesis-Stress Model

Main Question

Why do some people become addicted while others do not?

Main Idea

Addiction risk comes from both:

• Diathesis = genetic/biological vulnerability

• Stress = life experiences or environmental triggers

Genetic Risk

• Addiction has a heritable component.

• About 40–60% of addiction risk is linked to genes.

Main Takeaway

Addiction is not just about willpower. Some people have a stronger genetic vulnerability, and stress or environment can increase the risk.

Drug Addiction — Evidence from Studies (3 studies)

Evidence from Studies

Twin studies:

• Identical twins share more addiction risk than fraternal twins.

• This suggests genes matter.

Adoption studies:

• Adopted children have higher risk if their biological parents had substance abuse.

• This suggests inherited risk matters, even when raised in a different home.

Gene Findings

• Some genes increase general addiction risk.

• Some genes are linked to specific drugs.

• Many are related to dopamine signaling.

Drug Addiction — Comorbidity

Drug Addiction — Comorbidity

Main Question

Why does drug use often happen with other mental disorders?

1. Diagnostic Confounding

Diagnostic confounding = symptoms overlap, making diagnosis harder.

• Drug use can look like a mood or anxiety disorder, which can lead to misdiagnosis.

Main Takeaway

• Drug symptoms and mental disorder symptoms can overlap, so careful screening is needed to avoid misdiagnosis.

Examples of Overlap

Examples of Overlap:

Stimulant symptoms may look like mania/hypomania:

• euphoria

• high energy…

Withdrawal may look like depression:

• depressed mood

• no pleasure…

Depressant drugs may look like anxiety symptoms:

• poor concentration

• restlessness…

Possible Explanations

A person with substance use and mood symptoms may have:

• intoxication effects

• withdrawal effects

• substance-induced mood disorder

• preexisting mood disorder

• a combination of these

Drug Addiction — Comorbidity Table

Drug Addiction — Comorbidity Table

Main Idea

Many substances can cause symptoms that look like mental disorders, especially:

• bipolar symptoms

• depressive symptoms

• anxiety symptoms

• psychotic symptoms

• sleep problems

Important Point

Not all substances cause the same symptoms.

Clinicians need to check whether symptoms are:

• caused by the substance

• caused by withdrawal

• part of a separate mental disorder

Main Takeaway

Do not automatically diagnose a mood disorder when someone uses substances. First, check if the mood symptoms are substance-induced.

Intoxication vs. Withdrawal

Intoxication vs. Withdrawal

• I = intoxication

  • symptoms happen while using or shortly after using the substance

• W = withdrawal

  • symptoms happen after stopping or reducing the substance

Why This Matters

Drug effects can mimic mood disorders.

Example:

• A person may look depressed because of withdrawal.

• A person may look manic because of intoxication.

• A person may look anxious because of substance effects.

Drug Addiction — Comorbidity

Drug Addiction — Comorbidity

Main Question

Why does drug addiction often happen with other disorders?

2. Disorder Fostering Disorder / Kindling Hypothesis

One disorder can increase the risk for another disorder.

Example:

• A mood disorder may increase risk for addiction.

• Addiction may increase risk for a mood disorder.

Main Idea

One disorder can sensitize the brain, making the person more vulnerable to another disorder.

This means one problem may “unlock” or worsen the risk for another problem.

Shared Risk Factors

Shared Risk Factors

Mood disorders and addiction may overlap because they share:

• genetic vulnerabilities

• stress vulnerabilities

• brain dysfunction in similar regions

Important Brain Areas

Shared brain areas may include:

• prefrontal cortex

• hippocampus

• amygdala

These areas are involved in:

• emotion

• memory

• stress

• decision-making

• self-control

Main Takeaway

Drug addiction and mood disorders may co-occur because they affect similar brain systems. One disorder can make the brain more vulnerable to the other.

Drug Addiction — Comorbidity: Self-Medication & Depression

Drug Addiction — Comorbidity: Self-Medication

Main Question

Why does drug use often happen with other disorders?

3. Self-Medication

Self-medication = using drugs to reduce emotional pain or mental health symptoms.

People may use substances to cope with:

• distress

• suffering

• anxiety

• depression

• difficult emotions

• mood symptoms

Depression:

• A person may use stimulants to feel more energy.

• They may try to reduce low mood or lack of pleasure.

Mania:

• A person may use alcohol or opiates to calm down.

• They may try to control excess energy or insomnia.

Drug Addiction — Comorbid Treatments

Drug Addiction — Comorbid Treatments

Main Idea

When someone has both addiction and a mood disorder, treatment should target both problems.

Treatment Approach

• Addiction and mood disorders can be treated:

  • one after the other

  • at the same time

• Best approach is often combination therapy.

• Example: DBT may help with both addiction and mood symptoms.

Medication Notes

• There are no medications made specifically for dual diagnosis.

• Some medications may work better than others depending on the person.

Medication Strategy

Sometimes clinicians wait until detox/withdrawal ends before starting mood disorder medication.=

Why?

• Symptoms may improve on their own.

• It avoids confusing withdrawal symptoms with medication side effects.

Drug Addiction — Comorbid Issues

Diagnosis Issue

Ideally, a person would be off drugs first before diagnosis.

Why?

• Substance symptoms can look like mood disorder symptoms.

• Withdrawal symptoms can confuse diagnosis.

But waiting is not always realistic because delaying treatment can be harmful.

Possible confusing symptoms:

• nausea

• headache

• anxiety

• agitation

Drug Addiction — Integrated Group Therapy

Drug Addiction — Integrated Group Therapy

What It Is

Integrated group therapy is a form of CBT for people with both:

• bipolar disorder

• substance use disorder

Usually about 12–20 one-hour sessions.

Main Idea

Instead of treating them as two totally separate problems, therapy treats them as connected.

This is sometimes viewed as:

“bipolar substance abuse”

Goal: Treat both problems with equal importance.

The person learns how:

• bipolar symptoms can worsen substance use

• substance use can worsen bipolar symptoms

Focus

Therapy looks at similarities between:

• addictive thinking

• depressive thinking

Relapse vs. Recovery Thoughts

Relapse vs. Recovery Thoughts

Relapse thinking:

• “I may as well stay in bed.”

• “I may as well get drunk/high.”

Recovery thinking:

• “It matters if I go to a meeting.”

• “It matters if I take my medication.”

Main Takeaway

Integrated group therapy treats addiction and bipolar disorder together because each can affect and worsen the other.