Norman Jay Gersabeck, M.D.
ADDITIONAL INFORMATION ON SDIP: www.rust.net/~norman/
Citation: Gersabeck, N.J. (2000). Are tens of thousands
of the mentally ill being
misdiagnosed? International Journal of Psychosocial Rehabilitation. 5, 41-44
I have been working to establish the new diagnosis of substance dependency-induced psychosis (SDIP) for the past six years. It is a important and very common diagnosis, with likely half of all cases diagnosed as schizophrenic really being that of a SDIP. They are both functional psychoses and their signs and symptoms are quite similar. I serendipitously first used the diagnosis on a patient 26 years ago. He was a 45 year-old auto executive 3 months into his recovery from admitted alcoholism, with AA attendance as his only treatment. He had no other history for psychiatric problems and was doing well when an older brother unexpectedly died. The next morning he was confused and told his wife he "was afraid his car would tell his employer that he wanted to drink." (It was a company car and his company didnít want him to drink.) He had already been given the diagnosis of schizophrenia by another psychiatrist. I took over his case in the hospital about 3 weeks after the start of his illness, because of my position as consulting psychiatrist at the substance dependency treatment center where he had recently been treated for uncomplicated alcoholism. I shortly informed him of my very unofficial diagnostic impression. He largely accepted it, and this helped to further motivate him for lasting sobriety. After a year of often irregular outpatient treatment, he was able to safely get off all medication. For the remaining 15 years of his life, he functioned well and never drank again.
To summarize the support for the diagnosis, there have been three nationally known psychiatric experts in substance dependency who have supported further investigation of the diagnosis. The National Council on Alcohol and Drug Dependence (NCADD) added its support almost a year ago. Quite recently, the California Mental Health Dept. took the public-spirited, open-minded and even courageous action of informing all of its psychiatrists about the diagnosis. The "courageous" aspect of this action is that academic psychiatry "hasnít liked" this diagnosis because it clashes with its "biological ideology." It has largely dealt with the diagnosis by simply "stonewalling it." Biological psychiatry greatly emphasizes the role of genetics and "biochemical imbalances" in the origin of serious psychiatric illness. In doing so it is often guilty of overly reductionistic and simplistic thinking. Its very name represents a distortion of the dictionary meaning of the legitimate term, "biological." Its influence has had the very unfortunate effect of eliminating any training in ("unbiological") psychotherapy at many psychiatric training programs. At my web site www.rust.net/~norman is a very worthwhile and critical essay on "Biological Psychiatry" by psychiatrist David Kaiser, which is entitled: "Not By Chemicals Alone: A Hard Look At Psychiatric Medicine."
Academic psychiatry hasnít liked this diagnosis because it clashes with its 'biological ideology.'
The head of the addictive section of an eastern medical school psychiatric department was seriously planning to organize a clinical trial on the diagnosis two years ago. But this was largely prior to his assuming the post. Subsequently, he soon lost almost all of his interest and initiative regarding the diagnosis. I could only assume that he had underestimated the resistance of the psychiatric department to the diagnosis, and didnít want to deal with the inevitable hassle it represented.
I recently learned with some difficulty from the University of Melbourne (only) that it is currently conducting a clinical trial on what captures much of the essence of the SDIP diagnosis. This knowledge came about because a father from Australia had emailed me after having accessed my web site on the diagnosis. His 15 year old son had became mentally ill after abusing drugs during his parentís recent divorce, and was not doing well. He remarked that reading about the diagnosis was "like a breath of fresh air for him." I agreed with him that the diagnosis likely applied to his son. A few months, later I learned that his son was responding very well to treatment being offered at an outpatient treatment program, and that it was "much like I had recommended for SDIP patients." It was this knowledge that led me to learning that the son was a participant in a clinical trial. He was exceedingly fortunate to have such a concerned father, and to have lived near the only appropriate treatment program for him in the world. The father didnít want to reveal where his son was being treated- but I later learned that it was at the EPPIC (Early Psychosis Prevention Intervention Centre) program in Melbourne- which is aimed at young people.
I will be candid about this article. It is intended to inform- but also to motivate its readers to do whatever they can to support adequate media exposure of this diagnosis. I am convinced that the public has a right to know about this diagnosis, and that enough exposure will inevitably result in some medical school organizing a critically-needed clinical trial. I live in Michigan and the medical writer for the Detroit Free Press expressed real interest in reporting on the diagnosis earlier this year. Then about a month later, she mysteriously lost all her interest- and never would explain herself. I am convinced she belatedly learned of the "politically incorrect status" of the diagnosis. It is absolutely inevitable that the SDIP diagnosis will eventually become officially established. I would like this to happen sooner than later to avoid the preventable and very considerable suffering on the part of so many SDIP-afflicted persons.
The diagnosis of a SDIP is predicated on the pre-existence of a substance dependency, for which a variety of evidences point to its crucial role in the genesis of the psychosis. These include the timing of the illness, the nature of its symptoms, and the response to treatment. (One patient suffered his last auditory hallucination when he finally fully admitted to himself that he was alcoholic. This occurred six weeks into an outpatient substance dependency treatment program. A "voice" then said to kill himself. It was his first "voice" in months, and the first ever involving any suicidal ideas.) My executive patient likely would never have suffered a psychosis if he hadnít first become alcoholic. He also probably wouldnít suffered a psychosis if his brother had died several months later, when his alcoholic recovery would likely have been better consolidated. The first psychotic symptoms often develop during regular practice of the dependency. But they also often occur during periods of reducing or attempting to cease use of the substance because of increasing problems with its use. Probably the strongest evidence for the diagnosis is when a person first experiences symptoms very shortly after a return to (usually moderate) substance use- following a significant period of abstinence.
cocaine and marijuana
The most common substances involved are alcohol, tobacco, cocaine and marijuana (though tobacco only rarely by itself). The more substances involved and the greater the chronicity of the dependency, the greater is the likelihood of a psychosis later developing. Its first appearance is unlikely beyond a six month period from the last use of the substance. Its duration may be brief or it can last a lifetime. The latter can even be the case if the person never uses the substance again. Abstinence from all addictive substances (except nicotine and caffeine) is crucial- but often not sufficient by itself for recovery from the psychosis. It is abstinence, in the context of the person knowing he or she has a dependency, and learning about the vital causal role of the dependency in the psychosis which are the cornerstones of effective therapy for the SDIP patient. There are some state mental hospitals which have mental illness/substance dependency or dual diagnosis wards. These are a step in the right direction, and include some education on addiction. But the emphasis of treatment is on the need for abstinence because of the interference that any substance use has on the medication treatment of the psychoses. Of course, this is true as far as it goes- it just doesnít go far enough. The great majority of these patients do go back to some substance use. Knowledge of the causal role of the dependency doesnít automatically provide enough motivation for abstinence- but it helps.
It has been my experience that nearly all of the cooperative patients I have treated with a SDIP diagnosis have experienced considerable improvement over that of their previous psychotic diagnoses. Treatment has been mainly outpatient on a weekly basis for 3-12 months. It is of a individualized, educative, and insight-producing type- with the emphasis being placed on the dependency, its meanings and consequences of its practice for them. Fully a third have experienced full remissions, meaning no more medication is needed and that they have enjoyed a good return of function. The chances for the remission being permanent are good, providing they stay abstinent and otherwise maintain a good recovery from both the dependency and the psychosis. Either AA or NA attendance is a good idea for many of these persons. The average SDIP patient is less ill than the average schizophrenic patient to start with, and the treatment advantages of correctly making the diagnosis further improves the prognosis for these persons.
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