When Mood Meets Alcohol and Substance Use
Are we talking about craving or self-medicating or both?
Alcohol and substance use, bipolar, depression. "I have been sober and stable for nearly nine years now," writes Marsha, "and sometimes I feel like I'm going to lose it all. Everything I've worked for feels like it's just slipping away and I know I can't let this happen. My life depends on it. I do not have another recovery in me. For now all I can do is stay with my therapy, stay on my meds, and pray to God I make it through just one more day. For me one day at a time is all I can do, some days I have to take it minute by minute."
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Dual Diagnosis, Co-Occurring - How Severe Is It?
Welcome to the real world, where mental illness rarely is so considerate as to neatly dole out one disorder per person for easy diagnosis and treatment. In Marsha's case, Mother Nature has dealt her both barrels, a powerful double whammy - a mood disorder coupled with a substance use problem, commonly referred to as "dual diagnosis" or "co-occurring disorder."
In the fall of 2011, I experienced an aha! moment into the true severity of this condition. I was having dinner with a group of individuals involved in NAMI (National Alliance on Mental Illness). NAMI was founded in the late seventies by parents with kids with schizophrenia and all these years later these individuals still form the core of the organization's membership.
Inevitably, the conversation turned to their kids. The intractable nature of their illness, the heartbreak they put their families through, hospitalizations, homelessness, run-ins with the law, on and on. Naturally, I assumed they were talking about schizophrenia. Then one parent mentioned bipolar, then another, then another.
Bipolar? For the most part, even those facing severe challenges manage to settle into some kind of quasi-life. Yes, all hell may occasionally break loose, but the emphasis is on occasional. What I was hearing was different, way different.
You guessed it. It wasn't "just bipolar" I was hearing about. Thanks to drug and alcohol abuse in the equation, life's degree of difficulty for all parties concerned went from "challenging" to "just about impossible." The stories that night jibed with other accounts I had heard over the years from parents and loved ones, plus no end of conversations I have had with individuals experiencing the condition.
How bad is it? Recall, at first I thought these parents were talking about schizophrenia. That's how bad it is.
Cravings or Self-Medicating?
Walk into any AA or NA meeting, and you will hear people talking about their cravings. Walk into a DBSA (Depression and Bipolar Support Alliance) group and you will find some of these very same people talking about "self-medicating." Two different problems altogether or two faces of the same problem? It's hard to tell.
Craving implies an urgent need to satisfy an unyielding and insatiable desire, a desire that can neither be controlled nor satisfied. The same sense of urgent need is apparent in self-medicating, but this time in the context of release - however momentary - from the immediate hells inside our brain. But are the two all that different?
Population data suggests that self-medication is not exactly classic alcoholism or substance use served straight up. Fifty percent of those with lifetime mental illness also have a lifetime history of at least one substance use disorder. Six in ten of those with bipolar have experienced a substance use disorder some time during their life, more than five times the rate of the general population.
Thumb through AA's Big Book and you will hear a very compelling case for alcoholism (and by extension other types of substance use) as a physical disease, the failure of the body to control a craving for a specific chemical - a point of view validated throughout the science and treatment communities. Likewise, researchers have singled out a number of candidate genes for alcoholism and substance use.
Perhaps you can see where I am going with this. If all alcohol and substance abuse is strictly genetic, then why would these genes be so unevenly distributed? Why would they so heavily cluster in the mood disorders population? That can't possibly be right, can it? So what else can be going on?
A Failure in Impulse Control?
Mania is characterized by a breakdown in our ability to control our impulses. We tend to engage in behavior we would not ordinarily engage in. Dangerous and inappropriate behavior, including excessive alcohol and drug use. Thus the failure to control our impulses is not exactly the same as our lack of ability to control our cravings, though the two may overlap.
In alcoholism, a perfectly innocuous desire to have a drink becomes a dangerous craving. All things being equal, an otherwise rational and normal brain is overwhelmed by an irrational and abnormal urge. But with an individual experiencing mania, this appears to be turned around - the brain, in a temporarily irrational and abnormal state, fails to modulate even rational and normal urges.
Is life really all that simple? Absolutely not. But is this something to think about? You be the judge.
A Desperate Need for Release?
In the initial going at least, individuals tend to indulge in alcohol and drugs to feel better than they are currently feeling right now. Perhaps they are looking to feel euphoric and less inhibited, perhaps to numb their psychic pain, perhaps to feel an instant buzz. Some may continue to indulge for the same reasons, but for many the situation has changed. The crying need is for the chemical fix, not the feel-good state (which the brain may have built up a tolerance to).
With a mood disorder (not to mention vulnerability to stress) this is turned around. The overwhelming compulsion is for release from the psychic pain, be it depression or runaway mania or anxiety. A bit of feel-good (or feel less-bad) may be involved, but one is left with the sense of an individual putting out a fire or fleeing a burning building.
But, again, life is complicated. Addicts may claim they are self-medicating. Those who started off self-medicating may not recognize they have have turned into addicts.
Messed Up vs Clear Head
Some over-zealous participants in AA and NA caution that taking psychiatric meds is another form of chemical dependency. Fortunately, these people constitute a dwindling minority, though the dependency issue is in fact very real, especially with benzodiazepines. Just about all psychiatric meds require a slow wean to avoid rebound symptoms and withdrawal effects.
But people take psychiatric meds for entirely different reasons than those talking alcohol or recreational drugs. For the most part, there is no feel-good effect from a psychiatric med. No euphoria, no buzz, no hit, no trip, no sense of obliteration. Whereas an addict may start with an initially clear head for the purpose of getting it messed up, a person with a mental illness tends to be coming from the opposite direction.
Of all things, when researchers began investigating the inordinately high rates of cigarette smoking in those with schizophrenia, they discovered that nicotine had the momentary effect of restoring lost cognitive function. Think about it - for the first time in years or decades your brain is suddenly coming in loud and clear. To these individuals, the medically horrendous side effects are well worth the few precious seconds of mental clarity.
If nicotine came in a pill prescribed by doctors, with similar results, would you dare accuse these individuals of having a chemical addiction or dependency? (Nicotine agonists are in development.)
Contrast that situation with this account: A person addicted to alcohol and crystal meth was about to drive long-distance with his high-strung girlfriend, also addicted to alcohol and crystal meth. A well-meaning friend provided the girlfriend with some of his prescription anti-anxiety meds, one of the classes of psychiatric meds capable of being abused.
The friend naively assumed she would take them sparingly to remain calm and clear-headed. She took them all at once, with alcohol. Her intention was to get messed up, which is exactly what happened.
The Craving and Self-Medicating Factors
The inhibitory neurotransmitter GABA quiets down activity in the neuron, which is vital for keeping the brain in healthy stable state (homeostasis). Its tag team partner glutamate achieves a similar end through ramping up neural activity. Inevitably, when things go wrong, the two neurotransmitters are complicit in a range of mental illnesses and conditions, from anxiety to schizophrenia, with depression and mania thrown in for good measure.
When alcohol molecules bind to the neuron's GABA receptors, GABA transmission is increased. Because GABA is active throughout the brain, effects can range from euphoria to sluggish thinking to loss of muscle control. Over time, the neuron structurally changes to accommodate increased GABA supply, setting up the conditions for a craving.
Next neurotransmitter ...
Dopamine is central to pleasure and reward, motivation, alertness, executive function, and muscular control. Dopamine dysregulation (too much or too little) has been implicated in depression, bipolar, ADHD, OCD, aggression, novelty-seeking, schizophrenia, and Parkinson's.
Dopamine surges account for the highs from street drugs such as cocaine and crystal meth and prescription drugs of abuse such as methamphetamines, but these effects tend to wear off as the neuron structurally changes to compensate, again setting up the conditions for a craving.
Then there are brain systems involving serotonin (LSD and ecstasy work on this neurotransmitter), THC (cannabis), and stress regulation.
Since all these systems are intricately interconnected and interdependent, an addiction to one substance may involve an addiction to other substances. Likewise, mental illness and addictions share many of the same pathways. Serotonin has received most of the attention regarding depression, and it is no coincidence that ecstasy provides instant relief. Likewise, for vegetative depressions, a methamphetamine may offer a quick dopamine jump start.
Self-medication, then, is a clumsy and ultimately self-defeating attempt to bring the various brain systems into alignment. Think of alcohol, for instance, as an anti-anxiety med with an outrageous side effects profile. Ultimately, the short-term neurotransmitter surge sets up the conditions for the long-term depletion. Self-medication and craving become one.
The nature of alcohol and substance use disorders is that relapses are inevitable. Cynics often cite these high relapse rates as evidence that AA and NA do not work. To the contrary, AA and NA are tremendously helpful, though these programs obviously have their limitations and may not apply to everyone. Anne Fletcher's "Sober for Good" offers other choices. Her book recounts the recovery stories of 222 men and women who had serious problems with alcohol. Two-thirds had maintained sobriety for at least a decade.
More than half the people in the book quit without AA, many on their own, others through the help of therapists (especially those who practice cognitive-behavioral therapy), and others through non-AA groups such as Smart Recovery. The book quotes Rick, sober for 21 years: "There are probably as many ways to defeat alcohol problems as there are people who want to recover. The more choices we can offer, the more people can be helped."
Many conquered their drinking problems without ever seeing themselves as "alcoholics" with a "disease." Many took control of their drinking before they hit rock bottom, often making a lifetime commitment to stop rather than go "one day at a time."
Their greatest initial difficulty tended to be the absence of a crutch to help "escape, hide or get momentary relief from painful situations, troubles and feelings." Instead of masking emotions with alcohol, they eventually learned to recognize what they were feeling, and to allow themselves to experience it and express it in a healthier way.
Once they got behind the mask, they often found the real problem to be underlying depression or anxiety or relationship issues.
The Absurdity of a Divided Approach
Many people I have met in DBSA support groups clearly benefit from also attending AA and NA, but there are limits to this type of divided support. The AA and NA members I have met in DBSA groups to a person are very conscious of the fact that no one wants to hear about their alcohol or drug cravings, even though these may be very germane to their runaway moods. Likewise, I am sure, people in AA and NA don't want to hear about other people's depressions, even though these states may fuel their urge to drink or take drugs.
The divide exists across clinical services, as well - with sharply segregated specialities operating in their own isolated silos - despite the fact that expert opinion strongly supports integrated treatment. How ridiculous is that? Consider this passage from Voltaire's "Zadig."
Zadig was more dangerously wounded; an arrow had pierced him near his eye, and penetrated to a considerable depth. ... A messenger was immediately dispatched to Memphis for the great physician Hermes, who came with a numerous retinue. He visited the patient and declared that he would lose his eye. He even foretold the day and hour when this fatal event would happen. "Had it been the right eye," said he, "I could easily have cured it; but the wounds of the left eye are incurable." All Babylon lamented the fate of Zadig, and admired the profound knowledge of Hermes.
In two days the abscess broke of its own accord and Zadig was perfectly cured. Hermes wrote a book to prove that it ought not to have been cured. Zadig did not read it ...
So here we are, our entire treatment and support system in a state of myopia, with doctors of the left eye and doctors of the right eye not talking to each other, totally blind to the real phenomenon - dual diagnosis, co-occurring disorder, whatever you want to call it. Again, how bad is it? Recall my aha! moment with those NAMI parents.
By all means, get support and professional help. But the integration part is up to you. You clearly have your work cut out for you, but keep in mind four simple words - you are worth it.
This article replaces two eariler articles, May 20, 2011, updated Jan 16, 2012
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