Lifted from Edward Khantzian: The Self-Medication Hypothesis Revisited: The Dually Diagnosed Patient, in Primary Psychiatry, September 1, 2003,… as reproduced online at http://primarypsychiatry.com/the-self-medication-hypothesis-revisited-the-dually-diagnosed-patient/
In the case of schizophrenic disorders, an individual’s drug-of-choice and the way they use the drug is more complex. Each class of drugs is adopted differentially, depending on the particular symptoms that dominate or alternate in these conditions.
In reviewing the appeal of various addictive drugs for patients who suffer with schizophrenic disorders, it is important to distinguish between positive and negative symptoms associated with schizophrenia. Positive symptoms (paranoia, delusions, aggression, hallucinations, agitation, etc.) are usually appeased by drugs that have a calming effect. However, negative symptoms (alogia, affective flattening, anhedonia, asociality, apathy, attentional impairments) are probably significantly more important in determining reliance on addictive substances among schizophrenic patients than positive symptoms, especially if dependence on nicotine is taken into account.11 This is partially the result of the fact that negative symptoms are the residual aftermath of the more acute phase of schizophrenia when the patient is apt to be too disorganized to obtain or use substances of abuse. It also is the case that there is enormous suffering associated with negative symptoms, often not immediately apparent, that causes patients to resort to substances for relief of their suffering, even if it is only transient.
Positive symptoms presumably would be attenuated by analgesic opiates [e.g.: opium, morphine, Dilaudid, Fentanyl] because of the drugs’ calming and organizing action, especially with the accompanying rage and aggression associated with schizophrenia. However, with some rare exceptions where heroin is readily and easily available, schizophrenic patients are unable to obtain opiates because their disorganized condition in most instances makes them unable to negotiate the hazards to obtain opiates. However, alcohol is readily attainable by such patients, and is extensively abused by schizophrenic patients.
In obliterating doses, alcohol attenuates the voices, delusions, agitation, and anger for schizophrenic patients. As one patient put it, “I can dismiss them (the voices) and not be so distressed by them.” Low to moderate doses of alcohol counter the negative symptoms of asociality in such patients. A case in point, Albanese and colleagues published case material showing that when negative symptoms of patients, especially their inability to express their feelings and socialize, were relieved by the atypical neuroleptic clozapine, there was a corresponding decrease in patients’ unrelenting reversion to alcohol use.
There is a disproportionate abuse of stimulants among patients suffering with schizophrenia. This might be surprising given the psychotogenic properties of stimulants. However, there is evidence indicating that schizophrenic patients find relief from their anhedonia and other negative symptoms through the activating properties of stimulants, including nicotine. They also use stimulants to alleviate the sedating properties of neuroleptics.
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