Getting an accurate diagnosis can be complicated, and even elusive, when substance use is involved. The effects of substance use can masquerade as other mental health issues and psychiatric disorders. For this reason, many substance users who seek treatment will be misdiagnosed or underdiagnosed at some point. This is often a frustrating process. It’s not uncommon, for example, for one’s diagnosis to be unclear for some time especially if there are significant symptoms that could be attributed to a condition other than substance use. Further, it is also not uncommon for diagnoses to change throughout the course of treatment.
One of the major difficulties in obtaining an accurate diagnosis is that substance users often have a very complicated history of symptoms and stressors. Individuals who have used substances over a long period of time may have symptoms directly related to substance use and another disorder simultaneously. Also, especially for people who have had only brief periods of sobriety, it is not always possible to understand where past symptoms have come from. In these cases, history — although perhaps given honestly — is not always enough. A substantial period of abstinence may be required before a thorough evaluation can be completed and other disorders are diagnosed or ruled out.
Even for some who seek intensive help, such as a psychiatric hospitalization or inpatient substance treatment, a complete evaluation may not be possible right away. Often times, inpatient treatment is provided in brief stays that focus only on acute problems and immediate needs. Inpatient substance treatment programs, for example, are typically time-limited. Their focus is usually to provide a safe detox and equip the client with skills needed to remain sober in the community. It is not unusual, however, for people with substance use disorders to also have other psychiatric issues.
To further complicate the issue, many psychiatric conditions have symptoms similar to those found in substance use disorders. For example, symptoms like depression and anxiety are particularly common among substance users. These symptoms may also, however, indicate other conditions that do not involve substance use such as a clinical depression or anxiety disorder. Additionally, depression and anxiety are common for some time in early substance recovery — both during and after detox. Therefore, care providers who are seen in early recovery may not be able to determine if depression and anxiety are simply symptoms of early sobriety or if they indicate another co-occurring condition. The same diagnostic dilemmas are true for other mental health problems that substance users may have such as mood swings, impairments in thinking and even the experience of psychotic symptoms like hallucinations and delusions.
Psychiatric disorders are categorized by symptoms. A great deal of diagnostic procedure involves determining where symptoms come from. Furthermore, almost every symptom of psychiatric distress could be caused by several distinct conditions and could also be related to some type of substance use. For many, only time will tell — especially time in which one is abstinence from substances. Abstinence over a period of time will give the best clinical picture.
Some of the major categories of psychiatric conditions that are not related to substance use are:
• mood disorders such as depression, mania, and bipolar disorder
• anxiety disorders such as panic, compulsive behavior, phobias, reactions to trauma and obsessive thinking
• cognitive disorders such as delirium, dementia and amnesia
• schizophrenia and other psychotic disorders in which there is a break with reality
Notably, all of these can be ‘mimicked’ by substance-related symptoms. For example:
• Substance-Induced Mood Disorders can appear to be clinical depression and mania. Many substance users are chronically depressed but will not be after a period of abstinence. Also, some substances are so sedating that users will appear to be depressed when they are not. Similarly, stimulants, like cocaine or methamphetamine, cause the type of euphoria, agitation and sleeplessness that a manic episode would cause.
• Substance-Induced Anxiety Disorders can appear to be such conditions as panic attacks and Obsessive Compulsive Disorder. They can even be confused with reactions to stress and trauma. When related to substance use, however, anxiety is more likely to be caused by the physiological effects of intoxication or withdrawal.
• Substance-induced cognitive disorders can appear to be amnesia, dementia or delirium that is not related to substance use. A condition such as Persisting Amnestic Disorder is caused by the use of substances. It involves permanent memory loss (or amnesia) long after detox. Similarly, Substance-Induced Persisting Dementia involves, for example, the inability to think clearly, the inability to understand language or to express one’s self. It can appear to be dementia that is not caused by substance use. Finally, Substance-Induced Delirium involves such symptoms as disorientation and being out of touch with reality. All of these substance-induced conditions are caused by the toxicity of substances.
• Substance-Induced Psychotic Disorder involves hallucinations and delusions. This condition is directly related to substance use. Hallucinations and delusions can occur during intoxication or during withdrawal. This condition can appear to be a severe mental illness like schizophrenia that is not caused by substance use. A substance-induced psychotic disorder is caused by the toxicity of substances.
While an accurate diagnosis is invaluable, people with substance problems may have to wait a significant period of time to receive one–especially if there is suspicion that another mental health disorder may be present. Typically, a substance use problem so dramatically affects functioning and symptoms that it must be resolved in order to see what is left. Problems in obtaining a complete final diagnosis do not mean that mental health symptoms should be treated after the symptoms of substance use are. In fact, it is a medical best practice to treat both simultaneously. People with symptoms that could come from both a substance disorder and another disorder can receive successful treatment for all their symptoms at the same time. It is the origin of symptoms that will be clarified over time. Once it is clearly understood where symptoms come from, an effective long-term care plan can be developed. For this reason, it is important that individuals who use substances, and seek treatment for distressful symptoms, continue to see clinicians who are able to assess the origin of symptoms and make appropriate recommendations for care over an extended period of time.