Many people who use psychoactive drugs (including alcohol) do so with little or no adverse consequences. However, some people’s use becomes so regular, or of such a quantity, that it causes problems.
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Christopher Littlejohn, PGDipAlcohol and Drug Studies, BSc (Nursing), BSc (Psychology), RMN, is charge nurse, Tayside substance misuse services, Dundee
Problematic use often meets the criteria for substance use disorder (SUD), such as substance abuse (Box 1), or substance dependence (Box 2). Potential substance-related problems include the following:
- Physical and psychological ill-health;
- Disability and premature death;
- Interpersonal conflicts;
- Legal problems;
Intoxication, withdrawal, or consequences of SUD (such as poor nutrition) can produce symptoms that mimic psychiatric disorder. Such symptoms usually resolve with the resolution of the SUD. However, some substances can precipitate psychiatric disorders that persist.
Conversely, some people experience psychiatric disorder yet do not use substances. However, many people with psychiatric disorder do use substances, not just to self-medicate for their symptoms, but for the same social reasons as others. However, psychiatric disorder can increase the risk of SUD. Substance use and psychiatric disorder are linked, with each able to influence the other, often in a negative, vicious circle.
One difficulty when treating people with a dual diagnosis is their level of motivation to address substance use. A client may seek help for depression, but be unwilling to address an alcohol problem (Scott et al, 1998). The transtheoretical model of change has proven helpful in understanding change as a process (Box 3) (Connors et al, 2001; DiClemente and Prochaska, 1998).
Psychosis and schizophrenia
A person’s experience of psychosis typically includes delusions, hallucinations (usually auditory), thought disorders (such as feeling one’s thoughts are not one’s own), and disorganised speech (American Psychiatric Association, 2000). Schizophrenia is a common form of psychosis. Substance use is higher among those diagnosed with schizophrenia than the general population (Batel, 2000).
Alcohol, tobacco and cannabis are commonly used by those with psychosis (Margolese et al, 2004). Substances are often used to relieve general feelings of unhappiness, boredom, or loneliness (Mueser et al, 1998). Unfortunately, even moderate substance use can worsen psychotic symptoms (Margolese et al, 2004; Mueser et al, 1998). While some who experience schizophrenia can be reluctant to address substance use, recent efforts to integrate motivational interviewing (Miller and Rollnick, 1991) with cognitive behavioural therapy for psychosis have been successful in improving outcomes in relation to substance use and general functioning (Haddock et al, 2003). Integrated approaches with concurrent treatment for schizophrenia and substance use are generally recommended (Mueser and Kavanagh, 2004).
Psychosis can occur during intoxication with amphetamines, cannabis, cocaine, hallucinogens, inhalants, and opioids, and during either intoxication or withdrawal with alcohol and sedatives (APA, 2000). Substance-induced psychosis will usually resolve following the cessation of substance use.
However, amphetamine psychosis can persist for weeks after stopping (Murray, 1998) and lysergic acid diethylamide (LSD) can provoke a prolonged psychotic experience (Abraham and Aldridge, 1993).
Most cannabis users do not experience psychosis and most people who experience psychosis have never used cannabis. However, there is evidence that cannabis use doubles the risk of developing schizophrenia (Arseneault et al, 2004). Cannabis use appears to raise the risk not only in those predisposed to developing schizophrenia, but also as a risk in its own right (Smit et al, 2004).
Antisocial personality disorder
The adult personality develops from the interplay between congenital temperament and childhood environment and experiences, providing a consistent way of behaving, thinking and feeling in the world (Stevenson and Oates, 1994). Personality disorder occurs when a way of behaving, thinking and feeling produces negative consequences, either for the individual or those around them (Paris, 2003). Childhood impulsivity, sensation seeking, low autonomic reactivity, hyperactivity, and aggression - when persistently present - can develop into conduct problems, which are in turn associated with antisocial personality disorder (ASPD) in adulthood.
ASPD, characterised by criminal behaviour, deceitfulness, impulsivity, aggressiveness, irresponsibility and a lack of guilt and remorse (APA, 2000), has been diagnosed in 24-30 per cent of opioid users (Kokkevi et al, 1998; Vaglum, 1998), and 18 per cent of those with alcohol use disorders (Vaglum, 1998).
ASPD has also been associated with subsequent psychotic disorders (Mueser et al, 1998) and is viewed by some as a potential causal link between SUD and psychosis (Mueser et al, 1998).
Borderline personality disorder
Sexual abuse is recognised as an important precursor for borderline personality disorder (Paris, 2003; Moncrieff and Farmer, 1998). While desperate to be cared for, those with borderline personality experience the world as a frightening and dangerous place where they are at constant risk of abuse and abandonment. They experience surges of anger and use self-destructive defences to cope, leading to manipulation, impulsivity, suicidal threats, gestures and acts. They also experience recurrent idealisation and devaluation in relationships, producing chronic interpersonal turmoil (Evans and Sullivan, 2001; APA, 2000).
Borderline personality disorder increases the risk of subsequent SUD (Paris, 2003). One study found borderline personality disorder in one-quarter of drug users in treatment (Kokkevi et al, 1998). Specific approaches, such as dialectical behaviour therapy, have been developed to treat borderline personality disorder including associated substance abuse (Linehan, 1993).
Affective and anxiety disorders
Depression and generalised anxiety disorder
A major depressive episode is differentiated from ‘everyday depression’ by the severity and duration of the experience (APA, 2000). Symptoms include depressed mood for most of the day - nearly every day for at least two weeks, reduced interest or pleasure in things, guilt, preoccupation with death and an inability to concentrate, along with physiological disturbances to sleep, appetite, and energy levels (APA, 2000). Epidemiological studies report one in six people with a major depressive episode also have an SUD (Myrick and Brady, 2003).
Generalised anxiety disorder is characterised by ‘excessive anxiety and worry’ that lasts for at least six months and produces psychological and physiological symptoms (APA, 2000). Psychotherapy can produce short-term improvements, but these disorders have an unfortunate tendency to recur (Westen and Morrison, 2001).
Depression and anxiety are common in those with primary SUD. Most people with alcohol dependence (80 per cent) complain of depressive symptoms, 30 per cent meet the criteria for having a major depressive episode, and half meet the criteria for generalised anxiety disorder (Myrick and Brady, 2003; Raimo and Schuckit, 1998). Alcohol is a depressant drug, and alcohol intoxication can lead to temporary yet severe depressive symptoms. Alcohol withdrawal is characterised by symptoms of anxiety and can produce depression. Heavy alcohol consumption is commonly associated with vitamin B complex deficiencies, which can lead to psychiatric disturbances including depression and anxiety (Lishman, 1997).
Benzodiazepine dependence produces anxiety and sometimes depressive symptoms upon withdrawal (Moller, 1999). Regular weekend use of ecstasy produces a mid-week depression, probably associated with serotonin depletion (Burgess et al, 2000). The long-term mental health consequences of regular ecstasy use are unclear.
Amphetamine intoxication usually produces euphoria, but can produce depression. Both amphetamine and cocaine withdrawal can lead to dysphoria (APA, 2000; Murray, 1998). In addition, SUD-related problems can produce stressful life circumstances that risk depressive and anxiety reactions. Depression and anxiety in those with alcohol dependence generally resolve within a month of abstinence (Raimo and Schuckit, 1998). However, not everyone is willing to consider abstinence as a goal and depressive and anxiety symptoms can be a barrier to achieving abstinence in those who are. A number of studies suggest that treatment with selective serotonin reuptake inhibitors can reduce both depressive symptoms and alcohol consumption in alcohol-dependent patients (Cornelius et al, 2000; Roy, 1998).
Among those with opiate dependence, 75 per cent experience an affective disorder during their lifetime (Myrick and Brady, 2003). Opioids were once investigated for their antidepressant effects (Emrich et al, 1982), leading to suggestions that some opioid users are self-medicating depression. However, it is likely the stressful lifestyle of the illicit opioid user makes a contribution to depression and anxiety. Initially heroin use can be a social activity among a particular subpopulation of like-minded people (Lalander, 2003). However, once it becomes an addiction, users become increasingly desperate and isolated. They spend time every day in pursuit of the drug (or money to buy it), using it to avoid withdrawal, leaving them unable to trust anyone (Lalander, 2003).
Weekly cannabis use during adolescence has been found to double the likelihood of depression and anxiety in young adulthood (Patton et al, 2002). Daily cannabis use increases women’s chances of depression and anxiety fivefold (Patton et al, 2002). Acute anxiety due to cannabis intoxication is reported by 22 per cent of users (Thomas, 1996). However, depression or anxiety in this group does not influence the use of cannabis. This suggests that cannabis is not primarily used to self-medicate depression or anxiety (Patton et al, 2002).
Between 50 and 60 per cent of those diagnosed with bipolar disorder will meet the criteria for comorbid SUD (Myrick and Brady, 2003; Watkins et al, 2001). Bipolar disorder has been described in a variety of subtypes, but generally involves alternating periods of major depressive episodes and manic episodes. A manic episode is characterised by persistent elevation of mood accompanied by symptoms such as grandiosity, over-talkativeness, distractibility, psychomotor agitation and the reduced need for sleep (APA, 2000).
The high association between the two diagnoses is because drugs can be used to self-medicate symptoms, and because intoxication and withdrawal can resemble bipolar disorder (Watkins et al, 2001). Amphetamine and cocaine can energise those experiencing depression, or can prolong the ‘high’ of those experiencing mania (Watkins et al, 2001). Prolonged use of stimulants can produce behaviour that appears manic (Raimo and Schuckit, 1998). This may explain why bipolar disorder has been identified in 20-30 per cent of those with cocaine dependence (Myrick and Brady, 2003). Opiates can reduce the intensity of mania in someone who wants to feel ‘normal’ (Watkins et al, 2001) and alcohol can reduce anxiety and agitation. However, alcohol withdrawal can produce psychomotor agitation (with or without psychotic features) that can be mistaken for a manic episode (Raimo and Schuckit, 1998).
Panic disorder occurs in 1.5 per cent of the population. It is one of the few psychiatric disorders with good evidence that people can have long-term benefits from psychotherapy with follow-up (Westen and Morrison, 2001). It is characterised by repeated panic attacks, along with persistent concern that another attack will occur, worry about what the implications of the panic attacks are and significant behavioural changes in response to the attacks. There may be agoraphobia (APA, 2000).
One-third of those with panic disorder also experience SUD (Myrick and Brady, 2003). More people with panic disorder than depression experience SUD (Katerndahl and Realini, 1999). The idea that people use alcohol and drugs to self-medicate panic attacks is not supported by the evidence. Among those with comorbid panic disorder and SUD, only 10 per cent report using alcohol to self-medicate, and six per cent report using illicit drugs to self-medicate (Katerndahl and Realini, 1999). Indeed, panic disorder precedes SUD in only 10 per cent of cases. The majority begin using substances first and then develop panic disorder. The most commonly used substance in those who subsequently develop panic disorder is alcohol (32 per cent), followed by stimulant drugs, such as amphetamine and cocaine (10 per cent) (Katerndahl and Realini, 1999). Because most people who develop panic disorder do not experience substance withdrawal, it is not necessarily a withdrawal-related phenomenon (Katerndahl and Realini, 1999).
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) arises as a consequence of exposure to a serious trauma. The traumatic event is re-experienced in nightmares and flashbacks. Efforts are made to avoid reminders of the trauma and the person may become ‘numbed’ or emotionally detached from the world. Generalised hyperarousal can result in sleep problems, outbursts of anger and an exaggerated startle response (APA, 2000; Volpicelli et al, 1999). Between 25 and 40 per cent of those with SUD have current PTSD (Myrick and Brady, 2003).
Alcohol dependence has been found in up to 84 per cent of US combat veterans with PTSD, and drug dependence in 44 per cent (Stewart et al, 1998). Those with SUD are 10 times more likely to experience PTSD as those without SUD (Myrick and Brady, 2003). Women are 2-3 times more likely to have comorbid SUD and PTSD than men (Volpicelli et al, 1999). This has been attributed to higher rates of sexual abuse of girls than boys during childhood, which independently raises the risk of PTSD as an adult (Volpicelli et al, 1999). SUD is experienced by 25-39 per cent of women with assault-related PTSD (Stewart et al, 1998).
While regular intoxication may increase vulnerability to being the victim of a traumatic event, for most with comorbid SUD/PTSD, the PTSD comes first (Stewart et al, 1998). The more serious the trauma, the higher the risk of subsequent SUD. Most of the evidence points to SUD developing out of attempts to self-medicate symptoms of PTSD (Volpicelli et al, 1999; Stewart et al, 1998).
Unfortunately, as much as SUD helps reduce the intensity of present symptoms, it actually worsens PTSD over time, especially in relation to substance withdrawal (Volpicelli et al, 1999; Stewart et al, 1998). An integrated approach that assists people to cope with their symptoms of PTSD before they address their substance use has been developed (Najavits, 2001).
The relationship between SUD and psychiatric disorder is complicated, but there is no doubt that SUD and mental health problems are often linked. Whatever the causal direction, comorbidity often complicates the treatment and resolution of both disorders, often presenting as a vicious circle that the person has trouble breaking out of. It is vital that nurses working with people with mental health problems, or people who use substances, have an understanding of the interaction between the two.