The International Journal of Psychosocial Rehabilitation

THE NEW AND PROPOSED DIAGNOSIS OF "SUBSTANCE DEPENDENCY-INDUCED PSYCHOSIS"


Norman Jay Gersabeck, M.D.

ADDITIONAL  INFORMATION  ON  SDIP: www.rust.net/~norman/
 

Citation:
Gersabeck, N.J. (1999). The new and proposed diagnosis of "Substance Dependency - Induced
Psychosis. International Journal of Psychosocial Rehabilitation. 4, 47-51


"Substance dependency-induced psychosis" (SDIP) is a very common type of functional psychosis that is caused by a substance dependency. All the cases of SDIP I have treated already had other psychotic diagnoses made (mainly schizophrenia) by other psychiatrists. SDIP is quite similar to schizophrenia in its symptoms, signs and psychodynamics. I could categorize it as a subtype of schizophrenia, but doing so would have had the disadvantage of minimizing the
important differences between the two diagnoses. One difference is that most persons with a SDIP would never have developed any type of psychosis without the "help" of a preexisting substance dependency. This agrees with the fact that the average SDIP person is less ill than the average schizophrenic person. The most significant difference lies in the better treatment opportunities for the SDIP person.

An article in "Lancet" (12/26/87) reported on a Swedish study which revealed that, among army conscripts, heavy cannabis users later developed what was diagnosed as schizophrenia at a rate almost six times that for non-users. It was also determined that the premorbid personalities of the users were significantly better than the non-users, who were also so diagnosed. These findings correlate well with my finding that the SDIP-afflicted persons are usually less ill than thosetruly suffering from schizophrenia. It also implies that genetic factors in SDIP are
very minimal.

Gary Forrest, in his book "Alcoholism, Narcissism and Psychopathology" wrote that "alcoholic persons very seldom evidence a schizophrenic adjustment prior to the onset of their alcoholism." He also noted that approximately 8-12% of alcoholic persons show psychotic symptoms during the initial two or three months of recovery.

To speak of the potentially great power of an addiction is not to be unscientific. This power is very real, and is capable of wreaking great and usually negative changes in a person's thoughts, feelings and behavior. For example, a sane and intelligent alcoholic man may knowingly and literally be drinking himself to death. Despite not wanting to die, he may still go on to actually kill himself this way. It is both logical and scientific to reason that this same compulsive power
could be employed somewhat differently within the mind to, instead, produce a psychosis. Of course, as an addiction, substance dependency has strong and intimate connections with non-substance addictions, like compulsive gambling. However, the latter are very much less likely to be a critical factor in causing a functional psychosis. Only part of the reason for this are the pharmacological effects of the various substances. The complex psychodynamic factors attached to the actual intake of the substance into the body are also important.

Actual or potential psychological regression is an important aspect of any substance dependency, and the behavior of many substance addicts gives clear evidence of this. Regression is a necessary correlate to the development of a irrational and largely unconscious symbolization and powerful overvaluation of the substance- and it is this that constitutes the learning process of becoming addicted. Enough regression can produce a psychotic degree of regression- or, in short, a psychosis. The usual result of a substance dependent person stopping the use of the addictive substance is a lessened degree of regression and, therefore, better functioning. But for some substance dependent persons the result can, instead, be the reverse. For example, in the case of an alcoholic person who reluctantly feels he must quit drinking after a second or third DWI offense, his powerful and regressive narcissistic aspect of the "self" may, in effect, refuse to give up its power level within the "self" that alcohol had previously facilitated. The development of a psychosis leads to the preferred alternative.

The powerful cause-and-effect relationship between a dependency and a resulting functional psychosis makes available an additional type of treatment for the SDIP person. An individualized type of substance dependency therapy, used in the context of its causal role in the psychosis, can be very effective for many patients. To be eligible for the treatment, patients must be motivated for improvement. They must also have an open mind for both having a substance dependency, and its possible role in having caused their psychosis. Substance dependency therapy here has the real advantage of being of a specific nature. This means that it is
capable of treating the core or basic cause of the disorder. Weekly outpatient psychotherapy sessions lasting from 3-12 months have been the rule. The therapist needs to be knowledgeable about substance dependency, psychotic illnesses, and dynamic psychotherapy. Sadly, very few mental health professionals have an adequate understanding of substance dependency.

In contrast, the only-symptomatic treatment of antipsychotic medication is essentially the only treatment that is available for the "true schizophrenic" person. This medication treatment is often quite effective, but it is associated with frequent and sometimes very serious side effects. The Harvard psychiatrist, Joseph Glenmullen remarked in a general fashion on this matter when he wrote (somewhat hopefully): "The psychiatric profession is now recognizing the limitations of the symptomatic use of antipsychotic medications and the value of psychotherapy in helping schizophrenic and other psychotic-prone individuals regain human connection in their lives."

Almost all of the patients who qualified for outpatient treatment of their SDIP illnesses experienced better functioning and a lesser need for medication than had been the case with their earlier diagnoses. Much more impressive is the fact that, in my experience, fully one-third of these patients eventually enjoyed a full remission of all psychotic symptoms. This means they no longer needed any antipsychotic medication and returned to normal functioning. The chances were then good that their remission would be a permanent one, provided they continue to abstain from all addictive substance use (except, often for cigarettes). AA or NA membership is also usually advisable to maintain remission.

The more chronic the substance dependency is, and the more substances are involved, the greater the likelihood is that there will eventually be a SDIP complication. The chance that any particular substance dependent person will eventually develop a SDIP complication is relatively small- but having the dependency at least doubles this likelihood. The nature and severity of the resultant psychosis doesn't seem to depend much on the particular addictive substance involved. Alcohol, marijuana and cocaine appear to be equally likely to cause a SDIP. Not surprisingly, alcoholism is the most common cause.

The onset of the psychosis most often occurs while the person is still using the substance, or is in the process of discontinuing or reducing it. The intervening period between stopping the use of the substance and the onset of a SDIP psychosis is not limited- but a case of SDIP rarely occurs beyond six months from the last use of the substance. A relatively common type of onset of a SDIP provides a very good clue to the diagnosis. These are cases where a person suffers his or her first psychotic symptoms and signs very shortly after a return to use of the substance. This usually involves moderate levels of intake, and occurs after a significant period of abstinence. The period of abstinence is often motivated for purposes of denial of the dependency.

To make the diagnosis of a SDIP, one must prove the existence of a substance dependency prior to the first (ever) signs or symptoms of a psychotic illness. This itself, doesn't make the diagnosis- but it does mean that a SDIP is rather likely. Of course, there can't be signs of an organic psychosis, such as delirium. The dependency diagnosis in most SDIP cases has not yet been made. Even in state hospitals that have a M.I./S.D. (mental illness/substance dependency) ward, many SDIP patients will be found on other wards. In making the diagnosis, it is important to find indications of temporal and symptomatic linkage between the practice of the addiction and the onset of the psychosis.

In outpatient populations of schizophrenic persons, one frequently finds occasional and usually very moderate use of addictive substances. Combined with the almost-always present history of a preexisting substance dependency, such behavior is an important clue to the presence of a SDIP. This use is always against medical advice. The finding of a person stopping the use of medication and resuming daily use of addictive substances virtually makes the diagnosis of a SDIP. Another important clue to the presence of SDIP is the finding that the person's desire for the substance has greatly diminished or even disappeared with the initial onset of the psychosis. As the psychosis lessens, the desire partially returns. These findings correlate with similar findings sometimes noted in the acute onset of depression in some substance dependents.

A few years ago, psychiatrist Norman Miller of the University of Illinois cited in a journal article of an incidence of 80% of state hospital patients with a schizophrenic diagnosis having an associated diagnosis of a substance dependency. A majority of these dual diagnosis cases actually have a SDIP, rather than a schizophrenic illness. Ordinarily, most of these dependency diagnoses wouldn't have been even made. One of the reasons for this is that the onset of the psychosis always helps to hide the dependency because of the resulting decreased desire and intake of the substance.

I fully agree with the psychiatrist's statistic, but not with his not-stated, but still obvious assumption concerning the sequence of the two disorders. He even posed the question as to "why so many mentally ill persons would be so prone to abuse alcohol and drugs." He uncritically went along with the "conventional psychiatric wisdom" on the subject. This "wisdom" erroneously holds that, in such dual diagnosis cases, the mental illness comes first. But this sequence can be easily disproved by simply taking a good history. Accepting this sequence conveniently avoids any consideration of the "much less biological," but
otherwise obvious possibility that the dependency could be causing the psychoses. I was disappointed, but not surprised, when he failed to answer either of two letters I sent him. In them, I attempted to answer "his question" by disputing his assumption about the dual diagnosis sequence- and its implications.

The origin of the current and predominant "biological psychiatric philosophy" has reflected the better understanding of neurophysiology, and the development of many worthwhile psychoactive medications. (I always use quotation marks for "biological" in this context because its true meaning is being abused.) Ironically, the desire to be more scientific has resulted in the introduction of a very subtle, but still troublesome ideological element into "biological psychiatry."

The influence of "biological psychiatry" has had the very regrettable effect of eliminating any training in psychotherapy at many psychiatric training programs. This anti-psychological action obviously implies the belief that the complex and basic functioning of our minds is, somehow, "not really biological." In other words, "biological psychiatry" regards our hopes, fears, beliefs, and experiences as not being particularly important in the development of mental disorders .  Instead, it greatly exaggerates the importance of genetic factors, which are expressed in "biochemical imbalances." This emphasis has been at the cost of largely ignoring the important emerging science of information processing- which, of course, intimately relates to psychology. Psychiatrist David Kaiser M.D. wrote an excellent essay for the "Psychiatric Times" (Dec 96) which was very critical of "biological psychiatry." It was entitled: "Not By Chemicals Alone: A
Hard Look At Psychiatric Medicine."

In his book, "Psychology of Science," the renowned psychologist Abraham Maslow strongly doubted that physical science could be an adequate model for behavioral science. The physicist Fritjof Capra, in his excellent book "The Turning Point," agreed with Maslow and cited the need for a paradigm shift away from the biomedical model- and especially so for psychiatry. He wrote: "The overwhelming majority of illnesses cannot be understood in terms of  the reductionist concepts of well-defined disease entities and single causes. The main error of the biomedical approach is the confusion between disease processes and disease origins- with neglect of the latter."

I am quite aware that I can be criticized for "unnecessarily being polemical for introducing the issue of 'biological psychiatry'" into a paper on the SDIP diagnosis. But it has been a hard reality that this psychiatric philosophy has been responsible for effectively, though largely passively, opposing the establishment of the SDIP diagnosis. Though there are other opposing factors, it has been by far the most important one. My now being in the position of conceiving of and championing the diagnosis is not the result of any brilliance on my part. Rather it is the strength of these opposing factors which has resulted in this diagnosis not having been established many years ago by others.

A few years ago, I received a very interesting report from a substance dependency therapist at a state hospital M.I/S.D. ward. She reported that, in somewhat over half of such dual diagnosis cases, the addiction clearly came first. However, for "biological psychiatrists" the significance of this finding is largely negated by the convenient "biological understanding" regarding this sequence. It is that most cases of schizophrenia and substance abuse start incubating about the same time in the late teens. Therefore, the substance abuse/dependency is considered to be merely secondary to the underlying subclinical schizophrenic processes at work.

There was a journal article ("Journal of Hospital and Community Psychiatry") which reported on the fact that 70% of persons with the diagnosis of schizophrenia at an inner city emergency room tested positive for cocaine use by urine tests. I felt that the conclusion of the authors of the article that the mental illness preceded the cocaine use was an exercise in "tortured ideological and automatic conformist thinking." It certainly didn't reflect any effort at
history-taking of these persons.

A very probable correlate of this incidence is the recently reported increased rate of schizophrenia diagnoses among inner city black males- but not females. This increase was reported in the context of a nationwide decrease in this rate. Inner city black males have been increasingly using a lot of addictive drugs-significantly more than the females. This gender discrepancy indicates two things about the males' increase in these diagnoses. One is the that increased stress of inner city life is not the reason. Since the females share the same basic gene pool with the males, this rules out genetic factors as explaining the gender discrepancy. In short, this finding goes against the "biological theorizing" that similar genetic factors that cause schizophrenia also cause the associated substance abuse/dependencies. Therefore, the latter can't be dismissed as very likely causal factors for the substance abuse-related functional psychoses, that are currently diagnosed as schizophrenic. The SDIP diagnosis is the best answer to this puzzle.

Another indirect support for the SDIP diagnosis is the recent establishment of the DSM-IV "substance-induced psychosis" (SIP) diagnosis. It is a highly flawed diagnosis, as it should have been limited to non-addictive substances (for example, prednisone). Yet, in practice, nearly all of such diagnoses made are associated with both an addictive substance and a dependency. Just as the two diagnostic names differ only in one word, their theory and practice accurately reflect this difference. The SIP diagnosis is a "biologically/politically correct" one which holds that its psychoses are completely a result of "direct physical effects of the substance." The SIP diagnosis also has the "biological advantage" of not encroaching at all on the diagnosis of schizophrenia- as the SDIP diagnosis definitely does. Significantly, the criteria of the SIP diagnosis completely ignore the issue of substance dependency. There are only the usual connotations of the term "substance" to tie it in to the subject of substance dependency.

The real etiology of addictive substance-related psychoses (SIP and SDIP), necessarily, is much more complex than the simplistic or reductionist reasoning behind the SIP diagnosis could possibly ever explain. Some idea of the problems with this type of thinking in relation to substance dependency is shown by an example. The same alcoholic man can react very differently to the same amount of alcohol, depending on the "set and the setting." He may respond with: somnolence in a library; tears at a sentimental movie; belligerence at a bar; being
the "life of a party;" being sexually passionate in the back seat of a car. Because of the SIP's theoretical "biological premise," the SIP diagnosis, necessarily, has the criteria of two very arbitrary 30-day time limits. It can't persist or have its onset from the last use of the substance occur any longer than that period of time. In contrast, the SDIP diagnosis can be quite brief, or last a lifetime. The latter can even happen when the person never uses the substance again.

The SIP diagnosis itself doesn't necessarily lead to the diagnosis of the usually-associated dependency, or not surprisingly, to its rational treatment. In short, in the case of addictive substance-related psychoses, the SDIP diagnosis would nearly always be much more appropriate to use than a SIP diagnosis. It would also apply to many more cases. An alcoholic man whose illness qualifies for the SIP diagnosis is likely to be simply advised by his psychiatrist to either avoid alcohol- or to just significantly limit his intake (because of his supposed increased "biochemical sensitivity" to it). It is the existence of the dependency
itself, whether active or not, which is the basic cause of a SDIP.

I first used the SDIP diagnosis 25 years ago for a 47 year-old alcoholic auto executive who had an uneventful stay at the substance dependency hospital where I was the psychiatric consultant. He had no other history for any psychiatric disorders. He was doing well in his recovery with AA as his only therapy. But three months into his recovery, an older brother unexpectedly died. The morning after hearing this, he awoke in a confused state and told his wife: "I'm afraid my car will tell my employer that I want to drink." (He drove a company car and his employer didn't want him to drink alcohol.) If his brother had died a few months further into his recovery, he likely would have been able to avoid a psychosis.

I took over his case a week after he was hospitalized, when his wife learned that I was on the staff of the same psychiatric hospital where he was admitted. She wisely realized that it would likely be advantageous for him to be treated by a psychiatrist who was knowledgeable about alcoholism. He had already been diagnosed as schizophrenic by the psychiatrist on call. With the help of medication, he was fully lucid by this time. He was an intelligent man and accepted my very serendipitous diagnosis. This was despite my telling him it was far from being an official diagnosis. My making the diagnosis was prompted by his delusion, and the fact that he was still early in his recovery.

He was able to safely get off all medication after about six months of weekly outpatient psychotherapy. He had to be persuaded to stop his low dosage of medication. Within a few days, he was finally feeling like his old self. This result was clearly a lot more than just the straightforward physiological effects of the medication being discontinued. Substance dependent persons are always strong placebo reactors. Besides no longer being needed, the medication had assumed a negative placebo role for him. He also experienced a strong desire to drink for the first time in a year.. Fortunately, it didn't last long, and he coped well with it. His medication had been vitally important to him- but it finally become a detriment to him.

He continued to function well, and for the remaining 15 years of his life, never took another drink, or had any return of psychotic symptoms. This outcome was facilitated by his regular AA attendance and his knowledge that any alcohol or other substance use would very likely cause a return of mental illness. This knowledge was a much more powerful motivation for abstinence than the standard psychiatric advice given to substance-abusing "schizophrenic" patients. It is simply that of avoiding addictive substances because they interfere with the treatment of the illness- which as far as it goes, is true.

A 35 year-old man suffered a relapse in his 14 year history of psychosis which resulted in a four-month and fourth hospitalization. I first saw him shortly after his discharge. He claimed his "going berserk," which required hospitalization, was caused by his exposure to "wood alcohol fumes," of unknown origin. He denied any history for substance abuse. It wasn't until months and considerable improvement later that he admitted he had used both alcohol and marijuana heavily from ages 16-19. During his first year of college, he abstained from both substances for six months. This followed a religious experience at church. He then suffered his first signs and symptoms of psychosis very shortly after his cautious return to substance use. He finally got honest with me after I suggested that the meaning of his "wood alcohol fumes" delusion was likely related to the fact that this type of alcohol was poisonous. Therefore, it could well symbolize "bad alcohol." This was in contrast to his predominant and earlier unconscious labeling of "good alcohol" that had characterized his early alcoholism. He alsotold me that he had drank two cans of beer before he "went berserk." This was the first alcohol he had drank in months.

A 30 year-old woman had experienced a SDIP (by history) of three months duration, where alcohol was the main problem. Twelve years later (with occasional moderate drinking) she experienced two episodes of having "crazy thoughts" which lasted only a few hours. On each occasion, the symptoms started within several hours of the "last cigarette," during an attempt to stop smoking. Each time the symptoms abated almost immediately, following her resumption ofsmoking several hours later. Clearly, these psychotic symptoms were not a result of a straightforward (biochemical) nicotine withdrawal. Instead it was her serious intention to quit smoking itself which was the critical precipitating factor. This mechanism correlates well with a SDIP, but not a SIP diagnosis.

A 25 year-old man with multiple alcoholism-induced brief psychotic episodes stated that either drinking alcohol or being psychotic had the (seductive) effect of making him "feel powerful and important." Nearly all of his psychotic episodes were caused by drinking alcohol and/or conflict about alcohol. One episode occurred as he was clearly getting ever closer to the "first drink," after three months of sobriety. These episodes finally stopped when he really got serious about recovery from his alcoholism.

The National Alliance for the Mentally Ill (NAMI) is an advocacy organization for persons who largely have schizophrenic diagnoses. Many NAMI members and recovering alcoholic persons share an antipathy towards the SDIP diagnosis. The great irony here is that neither group likes the idea of any intimate relationship as possibly existing between the disorders of substance dependency and schizophrenia-like psychoses. The NAMI members equate such a relationship as implying an unwanted and pejorative "self-inflicted" element to a psychotic illness or disease. A reverse prejudice is held by the alcohol group. They dislike the mere idea of any close association of alcoholism with any serious psychiatric illness being possible. Unfortunately, these "not nice" perceptions of the SDIP diagnosis work against the "really nice" advantages of being able to correctly make the diagnosis.

There is a former alcoholic patient of mine who has 24 years of good recovery. She has had to be strong to deal with her 32 year-old son's disabling mental illness. Aided and abetted by a very dysfunctional family background, he had started to regularly use alcohol and marijuana in his mid-teens. He was diagnosed as being schizophrenic in his early twenties, and has been on SSI ever since. She first contacted me a couple of years ago about her son. I told her then there was a good chance that he had a SDIP, rather than a schizophrenic illness. She was open to this possibility. She later understood and fully accepted my reasoning in telling her that, even without examining him, I was now virtually certain of his having a SDIP illness. This greater certainty was due to my learning that he had recently stopped his medication and started drinking alcohol daily for two months. Then he was involved in a drunken auto accident, in which he left the scene. Interestingly, his functioning didn't suffer during this time. But it certainly would have done so, if he hadn't then stopped drinking and resumed his medication.

It is a sure thing that the SDIP diagnosis will eventually become established. I am laboring to see that this occurs sooner, rather than later. If the diagnosis had been available when the woman's son first became psychotic, the chances are fairly good that he would now be living a relatively happy and productive life. Sadly, the son refused his mother's advice that he consult with me. His is a good example of the great amount of needless human suffering that is still occurring for lack of the diagnosis having yet become established.




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