Dual Diagnosis: The Problem with Diagnosing Mental Illness in Early Recovery

Everything about my experience as a dual diagnosis clinician has shown me that Occam’s Razor is the best possible means by which to understand a person and their condition.

Occam’s Razor¹ is a simple tool: It suggests that when multiple explanations are available, the one that makes the fewest assumptions is likely to be the most accurate. In other words, the Keep It Simple System - principle (K.I.S.S.) works well.

I’ve learned to embrace simplicity because it provides me with clarity. More importantly, I have learned to live with the unknowns.

Early Recovery = Muddy Waters

In the first six months of a person’s recovery from addiction, there is a significant amount of overlap in symptoms of different mental health conditions, and there are a million assumptions that seem entirely plausible and yet most of them will be erroneous.

The difficulty with accurately diagnosing a person in early recovery is that everything about the way we think, cope, feel, and perceive has been impacted by drugs and then impacted by the process of withdrawal and adjusting to life without substances.

Post-Acute Withdrawal Syndrome

Post-Acute Withdrawal Syndrome² is well documented and dictates that a person is likely to experience significant mental health symptoms that result from moving away from dependency on drugs or alcohol. Research findings vary but my experience is that the duration is generally six to eighteen months following withdrawal.

I’m dubious about all research and so I apply Occam’s Razor: Typically people get clean and sober because their life has so spiraled out of control to be completely unmanageable and undesirable.

• Why do we see that so many people in early recovery are depressed? - Why wouldn’t we be? Rock bottom is supposed to be depressing. 
• Why are we anxious, paranoid, or experiencing severe mood swings? - Well, because we have lost all control, have stopped running from our fears, and we’ve glimpsed the magnitude of change that lies ahead of us. All of this and we’re trying to come to terms with never using again by living our lives and working recovery one day at a time.

The Personal Baseline - Where We’re At

Unless there is a compelling medical issue, I suggest to my clients that they not accept any diagnosis in the first six months of sobriety.

Every person has a baseline. This is simply how we are most of the time. We have good days and bad but for the most part, people do not deviate significantly from the range of what’s normal for them.

The baseline of a person less than six months sober has the range of a rollercoaster. The good days can border on grandiosity and the bad days can involve suicidality. This alone explains why so many recovering addicts and alcoholics are misdiagnosed in early recovery.

According to the DSM (Diagnostic and Statistical Manual of Mental Disorders), just over 1 person out of every 200 in America may live with Bi-Polar Disorder. My experience clinically is that amongst those who were diagnosed in their first year sober, over 80% were diagnosed as Bi-Polar and nearly that many were also diagnosed with ADHD. This provides us with a choice of hypotheses that inevitably get researched in very strange ways.

We seem to envision a chicken and egg scenario in which we’re seeking causality instead of considering that we may be looking at one issue and not two (just addiction and not mental health).

Example: There are essentially two reasons why people are depressed; their brain chemistry is out of whack or their life is sad/unsatisfying.

For those who have problems with brain chemistry, many learn to self medicate with drugs or alcohol. Inevitably, they will still have problems with their brain chemistry after sobriety.

In the second case, it makes sense that the person who was sad/unsatisfied in life used drugs or alcohol to provide escape and an altered state of feeling. Following withdrawal, not only do they have every problem and insecurity that existed before they started self medicating; they also have the wreckage that their life has become since they started using.

Cleaning Up

I suggest to my clients that so much of what they live with is a NATURAL consequence of how they have lived and how addiction destroys. I urge them to slowly and gradually increase stability, security, and ultimately the quality of their lives exponentially.

Addicts and alcoholics are incredibly impatient people. We want shortcuts and we seek them ravenously. To suggest that a pill can alleviate our suffering is delightful to us. To suggest that we have an illness that we were born with (Bi-Polar Disorder, ADHD) takes us off the hook for a lot of accountability (It wasn’t my fault. I was manic!).

Diagnoses become prophecies and pills become solutions. We get prescribed mood stabilizers and feel a little less depressed and if the medication “worked” then we believe we have the illness. We get prescribed meds for ADHD and enjoy the pep that stimulant medications provide and so of course we agree that the label fits us. We make decisions based on what feels good and that’s what got us into trouble in the first place.

I certainly understand that folks do live with mental health conditions and addiction concurrently. I’m saying let’s be patient. Let’s try not to hit the moving target of the baseline of the newly sobered.

Let’s celebrate being free of addictive drugs by striving to avoid medication that is addictive and easily abused.

There’s an adage in AA, “Don’t believe everything you think.” Just because someone diagnosed you with a condition doesn’t mean they’re right or that they’re right once and for all!