Andrey Nailor, M.D.·Published 23 October 2008·11 min read
Key points
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.
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 Schizophrenia is a disorder of brain functioning that results in a characteristic set of symptoms.
Contrary to popular belief, no evidence exists that drug abuse causes schizophrenia.
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 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.
Written and revised by
Andrey Nailor, M.D.
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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. {pagebreak}
Bipolar Disorder Bipolar disorder is a biologically based psychiatric condition that can in some cases lead to significant impairment in functioning. The disorder used to be called manic-depression, a term that was somewhat misleading since the typical pattern of manic symptoms followed by depression is not always seen.
Good evidence exists that bipolar disorder is genetically transmitted. When we look at the family histories of people with the disorder, we often find that other family members have been diagnosed with it. Sometimes family members are alcoholic or have committed suicide. A history of clinical depression or schizophrenia often represents untreated bipolar disorder or a missed diagnosis in a previous generation.
The primary problem in bipolar disorder is the regulation of mood states. Under stress, the susceptible individual will have a change in mood that is out of proportion to circum-Bipolar disorder is a biologically based psychiatric condition that can in some cases lead to significant impairment in functioning. The disorder used to be called manic-depression, a term that was somewhat misleading since the typical pattern of manic symptoms followed by depression is not always seen.
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Good evidence exists that bipolar disorder is genetically transmitted. When we look at the family histories of people with the disorder, we often find that other family members have been diagnosed with it. Sometimes family members are alcoholic or have committed suicide. A history of clinical depression or schizophrenia often represents untreated bipolar disorder or a missed diagnosis in a previous generation.
The primary problem in bipolar disorder is the regulation of mood states. Under stress, the susceptible individual will have a change in mood that is out of proportion to circumstances. Manic episodes involve an abnormal elevation of mood, decreased sleep and appetite, increased activity, racing thoughts, overtalkativeness, and impaired judgment. Mild cases are termed hypomania, which means "just short of mania." Delusions of grandeur or religious delusions can occur in severe cases. Depressive episodes involve a lowering of mood, increased sleep, increased appetite or nervous overeating, lack of interest in activities, slowed thinking, and disturbed concentration. Thoughts of suicide and actual attempts are a common complication. A mixed state occurs when there are manic symptoms of overactivity, racing thoughts, and poor sleep in combination with an irritable or depressed mood.
We see a variety of patterns in bipolar disorder. In the classic pattern, episodes of mania are followed by severe depression with periods of remission in between. Some people have isolated episodes of mania with little depression; others have more episodes of depression and only a few of mania.
There are people with strong family histories of bipolar disorder who have only episodes of depression. Bipolar II, a less severe condition, involves episodes of hypomania alternating with depression. Cyclothymic disorder is characterized by an even milder instability of moods and is seen in people with a family history of bipolar disorder.
Changes in mood according to season also occur in some with bipolar disorder and are thought to be a reflection of the brain's ability to sense the amount of ambient light. A worsening of depression in the winter months and the onset of manic symptoms in the spring are common. Some people experience depression only in the winter months, with no symptoms during other seasons, a condition that is called seasonal affective disorder. The use of phototherapy (exposure to strong light for about twenty minutes a day) is helpful in these cases.
In bipolar disorder, periods of remission usually occur between episodes. Rapid cycling refers to a condition in which there are frequent episodes with little remission of symptoms.
Plotting a time line and charting the onset, duration, and type of symptoms is a useful adjunct to treatment and helps the person with bipolar disorder manage the illness.
The mainstay of treatment of bipolar disorder is the use of mood-stabilizing medications that prevent the shifts toward mania or depression. The oldest of these is lithium. Lithium is a low molecular weight ion that is administered in the form of a salt - for example, with a carbonate ion. It stabilizes the membranes of nerve cells and prevents the cycles of depression and mania.
Over the past twenty years, a number of medicines that are used to treat epilepsy have been found to be useful for bipolar disorder. The same mechanism that stabilizes brain cells and prevents seizures also prevents the mood swings of bipolar disorder. Valproate (Depakote) and carbamazepine (Tegretol) are two such medications being prescribed widely by psychiatrists. Some of the newer anticonvulsants also show promise in the treatment of bipolar disorder. Other medications such as antidepressants, minor tranquilizers, and antipsychotic medications are used to manage the different phases of bipolar disorder. It is important for a person with bipolar disorder to become familiar with all prescribed medications and learn to recognize symptoms of mania or depression in an early stage so as to prevent a full-blown episode.
Bipolar disorder can vary in severity from being a minor inconvenience to involving major impairment in all areas of functioning. Proper psychiatric management and careful compliance with treatment recommendations can reduce the disability associated with this disorder. Many people with bipolar disorder lead full and productive lives.
People with bipolar disorder are at particularly high risk of developing addiction. There may be a genetic vulnerability to both disorders. Also, people with bipolar disorder often attempt to alleviate their symptoms with alcohol or drugs, especially before the illness has been properly identified.
Substance abuse intensifies the symptoms of depression and anxiety over time. Judgment is impaired as the illness becomes active, and the tendency to abuse substances increases.
Some people with bipolar disorder come to enjoy feeling slightly manic. At the early stages of a manic episode, the heightened sense of well-being and increased productivity are similar to the effects produced by stimulants such as amphetamines or cocaine. People with bipolar disorder can learn to manipulate their medications to induce this feeling.
However, it's very difficult to control the effect. What usually happens is that the symptoms of mania worsen and judgment becomes impaired, leading to a loss of control.
Supportive and educative therapy is important for people with bipolar disorder, and an ongoing relationship with a psychiatrist or psychologist helps reduce the frequency of episodes. In severe cases, when there is significant impairment of functioning and judgment, case management is also helpful. {pagebreak}
Schizoaffective Disorder Schizoaffective disorder is a condition that has some aspects of schizophrenia and some of bipolar disorder or major depression. For example, hallucinations, delusions, and disorganized thinking might occur along with symptoms of mania, or severe depression might be accompanied by the disordered thinking typical of schizophrenia.
Treatment approaches for schizoaffective disorder involve an individualized combination of therapies. Antipsychotic medication along with a mood stabilizer is often used. Supportive psychotherapy, case management, and education are also important.
Major Depression Depression involves a characteristic set of symptoms but represents a diverse group of disorders. Most cases of depression are mild to moderate and short lived. As we've seen, depressive symptoms are common in addiction and are also frequently induced by alcohol or drugs. But in some cases depression is severe and prolonged and causes significant impairment in functioning. The condition can be broken down roughly into three types: reactive or situational, devel-opmentally based, and biologically based.
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Situational or reactive depression is common in alcoholics and addicts and generally clears with counseling and medication. Developmentally based depression often results from abuse or neglect in childhood or from growing up in a dysfunctional family.
Biologically based depression, or major depression, is a disorder that affects the part of the brain responsible for maintaining mood and handling stress. It can be mild, moderate, or severe. There is often a family history of major depression.
In some cases a trauma has occurred in childhood, such as the loss of a parent, which is severe enough to have affected the development of the brain, leading to a vulnerability to biologically based depression.
Symptoms include a persistently depressed mood, a lack of reactivity of mood to social interaction, slowed thinking, poor appetite, intermittent or early morning awakening, poor concentration, impaired short-term memory, and morbid preoccupation. Thoughts of suicide are often present, and there is a risk of suicide attempts. Some abnormalities in endocrine functioning have been noted, such as a blunting of the responsiveness of the thyroid gland and failure of the adrenal gland to respond to the presence of a test dose of dexamethasone (a steroid). In severe cases there may be hallucinations and delusions, often with morbid or depressed content.
Major depression usually responds to treatment with medications along with psychotherapy, but sometimes depression is resistant to treatment and leads to chronic problems with concentration, mood, and self-esteem. Addicts with treatment-resistant major depression often have difficulty with recovery since they do not share the apparent benefits of abstinence with their peers. They may also be overly sensitive to confrontation and have difficulty with the middle steps of a 12- step program.
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