The people who have had the most difficulty with the split between addiction and mental health treatment delivery systems are those who suffer from the major psychiatric disorders, which are chronic and cause significant functional impairment. These conditions include schizophrenia, bipolar disorder, schizoaffective disorder, major depression, and certain personality disorders. All are associated with an increased incidence of addiction. Over the last decade there has been a push toward the development of specialized dual diagnosis programming to help meet the needs of people with these conditions.
Let’s look briefly at each of these disorders and at how traditional alcohol and drug treatment approaches can be modified to enhance the chances of successful recovery for those who have them.
Schizophrenia is a disorder of brain functioning that results in a characteristic set of symptoms. We still do not fully understand what causes schizophrenia, but there is good evidence that there are several distinct subtypes with different causes and courses. Some cases appear to be genetically based; others seem to arise from a disruption in the development of the brain, a condition that remains dormant until the person reaches a certain age.
Contrary to popular belief, no evidence exists that drug abuse causes schizophrenia. With the exception of PCP-induced psychosis and alcoholic hallucinosis, most psychotic conditions induced by drugs will readily clear with abstinence and do not become chronic. However, individuals who are biologically predisposed to develop schizophrenia can, by abusing drugs, bring about the onset of active symptoms.
The term “schizophrenia” does not mean “split personality”; it literally means “split mind,” but the word is used to describe the disorganization of thinking and emotions that characterizes this disorder, not the splitting into several distinct personalities that is is seen with multiple personalities.
Roughly 1 percent of the population suffers from schizophrenia, and many of these people have significant impairment in their overall functioning. Symptoms generally appear in the late teens or early twenties, although some cases begin during childhood or later in life. Subtle childhood problems with tasks such as learning to socialize may be identified retrospectively in people who later developed schizophrenia.
Psychotic symptoms such as hallucinations and delusions are seen during active phases of the disorder. In periods of remission, many people still have significant residual symptoms such as a blunting of emotional responsiveness or a decrease in the acuity of their thinking.
Disordered thinking and ability to reason are characteristic of schizophrenia. As a result, many people with schizophrenia have impaired judgment, especially in social situations. It’s common for people with schizophrenia to experiment with drugs and alcohol in an effort to fit in socially, as it is for them to abuse illicit drugs in order to self-medicate ongoing symptoms or to reduce uncomfortable side effects of medication.
Some people with schizophrenia also develop addiction.
If there is a genetic susceptibility to alcoholism or addiction or prolonged abuse of alcohol or drugs, addictive disease can occur, which means that the person has two serious and chronic mental health problems.
People with this disorder are often uncomfortable in social situations and in groups. The technique of direct confrontation that is used in many traditional alcohol and drug programs to address denial and personality flaws is threatening to people with schizophrenia, and they may experience a worsening of the symptoms of psychosis as a result of this stress.
Some of those with schizophrenia have difficulty maintaining attention to lectures, watching videos, and completing workbook assignments because of problems with the intellectual functions of attention, concentration, and memory that accompany this disorder. A good deal of the work done in traditional alcohol and drug treatment centers involves these types of activities, and someone with schizophrenia may seem noncompliant or uninterested if the clinician does not understand the person’s difficulties in completing such tasks.
A lack of insight is another problem found in those with schizophrenic disorders. It was once thought that this char acteristic was of psychological origin, but there is now good evidence that it is the result of a brain dysfunction caused by the schizophrenic disorder. The person may not realize that he or she has a mental illness and is in need of treatment, a lack of understanding that is sometimes mistaken for denial by clinicians who work primarily with addictions. Applying the same methods for reducing denial in those with addiction to a person who has a schizophrenic disorder is a frustrating experience for the clinician as well as for the patient, and often leads to the patient leaving treatment.
Schizophrenia is usually managed with a combination of medications for the psychotic symptoms and supportive therapy and counseling. A case manager, someone who serves as a contact person and facilitator, can be very helpful in fostering compliance with treatment and gradual progress towards stabilization. Psychoeducation is a combination of teaching and therapy that presents in a nonthreatening manner the facts of the illness and ways in which to manage it. People with schizophrenia need to learn how to manage stress, identify symptoms, and communicate effectively with caregivers.
Schizophrenia is a chronic illness with a relapsing course, but newer medications and treatment techniques have come a long way in reducing the impairment and disability caused by it.