Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

274 IV. SPECIAL POPULATIONStreatment for both; the exception is patients who present with temporary psychiatricsymptoms caused by the substance use or its withdrawal.Meyer (1986) suggests considering six possible ways in which substance useand other psychopathology may be related:1. Psychopathology may be a risk factor for SUDs. As described previously,studies of patient and community samples have shown that the risk of having aco-occurring SUD is elevated in persons with psychiatric disorders. For example,dopaminergic dysfunction in patients with schizophrenia has been hypothesizedto increase their risk of SUDs—particularly cocaine use disorders (Greenet al., 1999; Smelson, Losonczy, Kilker, et al., 2002). Another theory, widelyknown as the “self-medication hypothesis” (Khantzian, 1989, 1997), suggeststhat psychopathology leads patients to use substances in an attempt to decreaseunwanted psychiatric symptoms. For example, a patient with insomnia due toPTSD nightmares may use alcohol or marijuana to induce sleep. Althoughresearch has not found direct connections between particular psychopathologicalsymptoms and specific substances (rather, patients tend to misuse a widevariety of substances to “treat” a range of symptoms), the general principle is animportant one. It is discussed in more detail in the next section.2. Psychiatric disorders and co-occurring SUDs may serve to modify the courseof each other in terms of symptomatology, rapidity of onset, and response to treatment.Also described earlier, there is considerable evidence that comorbidity isassociated with worse outcomes. Additionally, there is evidence that patientswith schizophrenia and co-occurring SUDs do not respond as well as thosewithout SUDs to similar doses of first-generation antipsychotic medications(Bowers et al., 1990).3. Psychiatric symptoms may result from chronic intoxication. Drug and alcoholuse can result in a variety of psychiatric symptoms, such as depression, anxiety,euphoria, psychosis, and dissociative states. Most such symptoms disappear,however, within hours (e.g., cocaine-induced paranoia) (Satel, Southwick, &Gawin, 1991) to weeks (e.g., alcohol-induced anxiety or depression) (Brown,Irwin, & Schuckit, 1991; Brown & Schuckit, 1988).4. Long-term substance use can lead to psychiatric disorders that may not remit.Alcohol-induced long-term cognitive changes, such as those seen in alcoholinducedpersisting dementia, exemplify one way in which chronic use of a substancecan create enduring change.5. Substance abuse and psychopathological symptoms may be meaningfullylinked. Some individuals may use alcohol or drugs in ways that enhance theirpsychiatric symptoms. For example, patients with ASPD may use alcohol orcocaine, seeking disinhibition and aggression, and patients with bipolar disordermay use cocaine or other stimulants to augment a euphoric mood (Weiss,1986l; Weiss et al., 1988).