As you probably know by now, I have been replacing a lot of the old articles on mcmanweb with brand new ones. More recently, my focus has been on disorders that overlap with mood, including schizoaffective and anxiety. This time around, it's alcohol and substance use. Following is an edited extract ...
Walk into any AA or NA meeting, and you will hear people talking about their cravings. Walk into a DBSA 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.
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.
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 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. Some may continue this way, 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 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.
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. 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.)
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.
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