Tag Archives: Substance Abuse

S – #AtoZChallenge on Mental Health

Welcome to day 19 in the #AtoZChallenge on mental health. We’ve arrived at the letter S. Here goes.

Self-Injury

Self-injury or self-harm is the deliberate infliction of wounds upon oneself. Some scientists make a distinciton between self-injury and self-harm. Self-injury is then seen as leaving relatively minor, local wounds such as cuts or burns. Many people with depression, anxiety or emotion regulation issues such as in borderline personality disorder self-injure. Self-harm then is the infliction of grave harm onto the self, such as amputation. This is seen more often, according to these scientists, in people with psychotic disorders such as schizophrenia. In reality, of course, only a small portion of even the most severely psychotic patients engage in severe self-mutilation.

In DSM-5, non-suicidal self-injury was introduced as its own mental health diagnosis. Prior to that, many people who self-injure were misdiagnosed, often with borderline personality disorder. The DSM-IV guidelines even said that, if someone self-injured to cope with overwhelming emotions, BPD should be diagnosed, even though BPD has nine criteria, five of which must be met for a diagnosis.

Self-Medication

Self-medication refers to the abuse of alcohol or drugs with the goal to cope with mental health problems. It can also refer to the use of prescription medications that haven’t been prescribed to that specific person. Many people “self-medicate” with alcohol, even though alcohol does not have any medical benefits (except in mouthwash). In fact, it can make symptoms worse. Same for drugs. For instance, many people with psychotic symptoms use cannabis because it seems to calm them, even though it is in reality thought to worsen psychotic symptoms.

Of course, some drugs sold on the streets actually do help with certain symptoms. For example, people with undiagnosed ADHD might start using stimulant drugs to counter their symptoms. It is for this reason that self-medication needs to be taken very seriously. In my post on dual diagnosis last October, I addressed the complicated relationship between alcohol or drug use and mental illness

Survivor

Many people were and still are treated for mental illness against their will. In the antipsychiatry movement, people who come out of (forced) psychiatric care are seen as survivors. Many mentally ill people have indeed endured traumatic experiences at the hands of professionals. Many also have had other traumatic experiences, which may’ve contributed to their mental health condition. As such, they’re also survivors.

Dual Diagnosis: Addiction and Mental Illness #Write31Days

31 Days of Mental Health

Welcome to day 19 in the #Write31Days series on mental health. I am terribly late to write my post today and not really motivated for it. You see, I came down with a terrible cold and an earache. Life must go on though. Today, I’ll discuss a topic that does not affect me personally, but does affect many people I know in the psychiatric institution: dual diagnosis.

Dual diagnosis describes the co-existence between an addiction and a mental illness. The relationship between substance abuse and mental illness is complex. There may be many reasons why addicts get mental illness and why people with mental illness become addicted. For instance:


  • People with mental illness may use alcohol or drugs as a form of self-medication. This means that, when they experience undiagnosed or undertreated symptoms of mental illness, they turn to drugs or alcohol for a “quick fix”. They think they feel less anxiety or depression, for example, when high on durgs. Unfortunately, while this may temporarly seem true, substance abuse makes these conditions worse.

  • Symptoms of mental illness can be worsened by substance abuse. For example, a person who is depressed might experience suicidality when intoxicated with alcohol, or a person with an anxiety dsorder may experience worse anxiety when withdrawing from opiates (eg. heroin).

  • Substance use can cause symptoms of a mental illness to appear in otherwise healthy people. The most common example is maijuana leading to psychosis. This is often called a drug-induced psychosis. Unfortunately, drug-induced psychoses may set in motion a rollercoaster that leads to longer-lasting problems, ie. schizophrenia.

According to the Amercan Medical Association, 35% of people who abuse alcohol and 53% of those who abuse drugs have at least one co-occurring mental illnesss, and 29% of people diagnosed with a mental illness are substance abusers. Males and young adults are more likely to experience dual diagnosis than do females and older adults.

The treatment of co-occurring mental illness and addiction is harder than that of either condition alone. It may be hard to diagnose the individual with co-existing substance abuse and mental illness because of the interactions between the two. For instance, if a person abuses amphetamines, it may be hard to recognize they do so as a means of self-medication for undiagnosed ADHD.

Violence and suicidality are more common in the dually diagnosed than in those with a mental illness alone. People with mental illness who end up in jail for criminal behavior (not just drug-related crimes) are also more likely to have a co-existing addiction.

Because many psychiatric hospitals and drug rehab centers treat only those with either a mental illness or an addction, people with a dual diagnosis have a harder time accessing treatment for any of their problems. Fortunately for them, there are now dual diagnosis units in many psychiatric hospitals at least in the Netherlands. I say “for them”, because the larger population of dually-diagnosed people in psychiatric hospitals does cause at least some people with just a mental illness (ie. me) to feel unsafe.

Benzodiazepine Use: Benefits and Risks

A few days ago, I was sent an E-mail requesting I post an infographic on my blog about the dangers of benzodiazepines. The infographic was created by a dual diagnosis recovery center for people with a mental illness and co-occurring addiction. Because it is very much focused on the U.S. situation, I cannot repost the infographic here without further comment. I don’t do that anyway. Instead, I’m also sharing my knowledge of and experience with benzodiazepines, their benefits and risks.

The Hidden Dangers of Benzos
All rights reserved. Attribution: first posted on DualDiagnosis.Org

Benzodiazepines are a class of tranquilizing medications, among which are diazepam (Valium) and lorazepam (Ativan). While they can legally be prescribed for a range of conditions – insomnia, anxiety, panic attacks, seizures, etc. -, the Dutch insurance system limits coverage for benzodiazepines to four conditions:


  • Maintenance treatment of epilepsy or as-needed treatment of an epileptic seizure.

  • Treatment of anxiety disorders, when treatment with at least two antidepressants has failed.

  • Treatment of multiple psychiatric conditions that require use of high doses of benzodiazepines.

  • Palliative sedation during end-of-life care.


Physicians who prescribe benzodiazepines for these conditions, need to add the code B2 to the prescription.

I have used benzodiazepines on several occasions. First, in 2006, I was prescribed a benzodiazepine sleeping pill. It was at the time still covered, but no longer would under the current insurance regulations. However, from 2007 on, I’ve used several benzodiazepines for PRN use for irritability. Whether this falls under the multiple psychiatric conditions rule, I do not know, since I am in an institution so medications are covered anyway.

In 2010, I was on Ativan daily for three months. I was on a moderate dose of 3mg/day. After these three months, I told my psychiatrist I felt I no longer needed the Ativan. He changed the prescription to as-needed and I quit taking the benzodiazepine cold turkey. That truly wasn’t a wise choice. A few days from quitting, I was trembling and shaking. At first, I thought it was the antidepressant I’d started taking three weeks prior, but I eventually realized I was probably experiencing Ativan withdrawal. I spoke to my psychiatrist, who put me on a taper schedule that took several months. Ultimately, I spent almost as long trying to taper the Ativan as I’d been on it.

I honestly never found relief from benzodiazepines. Usually, I slept for a few hours then was irritable again. Then again, it seems that with irritability, the goal is to knock you out, not to really make you feel better. I also learned recently that benzodiazepines should really not be prescribed to people with borderline personality disorder, as the anti-anxiety effect causes borderline patients to be disinhibited and potentially become aggressive. I don’t think I ever experienced this myself.

I tend to develop tolerance to benzodiazepines really quickly. With the sleeping pill I took in 2006, I was given ten tablets that I used up over a six-week period. No daily use at all. Still, the last few pills didn’t really work at all. Please realize that, if you got used to one benzodiazepine, you’ll likely develop tolerance to the next pretty soon too. In November and December of 2007, I was on three different benzodiazepines, with about ten benzo-free days in early December. The first, I got used to within five days but kept taking for a month anyway. Then I had the ten days when I was off benzos – but on a stronger tranquilizer that is really an antipsychotic. Then I started taking nitrazepam (Mogadon), one of the more expensive benzos out there. It worked for about two weeks, but I did use the neuroleptic as adjuvant treatment. By the time I’d gotten used to the Mogadon, my doctor thought it would be time for something other than a benzo, but the psychiatrist disagreed and put me on diazepam. That didn’t work and I quit all tranquilizers at the end of December.

I have not been on any benzodiazepines for about a year now. I took Ativan as-needed until the summer of 2013, but it hardly worked so I now take promethazine (Phenergan), a low-potency neuroleptic. I do not want to be on benzos anytime soon again. Then again, I don’t suffer from epilepsy or a significant anxiety disorder and my irritability is kept relatively under control by a daily antipsychotic and PRN Phenergan.

When I ran the above infographic by some fellow bloggers to determine whether it was genuine, some people told me they did great on benzos. If you’ve suffered from severe anxiety for a time and antidepressants have not worked, I can totally see why you’d try benzodiazepines. If you have epilepsy, something has got to drag you out of a seizure. Therefore, even though I have personally not had luck with benzos, I don’t want to say that benzodiazepines are necessarily bad. I like the Dutch insurance policy, making sure that people won’t reach for benzos too soon but those who need them, can get them.

The Five Stages of Grief in the Recovery Process from Binge Eating

When browsing blogs on mental health on Mumsnet, I came across a blog on recoveyr form alcoholism. While there, I found a post on the five stages of grief in substance abuse. You are probably familiar with Elisabeth Küber-Ross’ five stages of grief in bereavement. These same stages apply to some extent to those recovering from an addiction:


  • Denial: people feel that they do not have a problem concerning alcohol or substances. Even if they do feel as if they might have a small problem, they believe that they have complete control over the situation and can stop drinking or doing drugs whenever they want.

  • Anger at the fact that the addict has an addiction or at the fact that they can no longer use alcohol or drugs.

  • Bargaining: the stage where people are trying to convince themselves or others that they will stop substance abuse in order to get out of trouble or to gain something.

  • Depression: sadness and hopelessness, which usually happen during the withdrawal process from alcohol or drugs.

  • Acceptance, not merely as in admitting you have a problem with alcohol or drugs. Acceptance involves actively resolving the addictioon.

I do not have an alcohol or drug problem, but I do exhibit disordered eating. I wonder to what extent these stages of grief apply to the recovery process from eating disorders, in my case mostly binge eating. Denial is certainly common in individuals with all types of disordered eating. I for one was in the stage of denial up until quite recently. This is not merely not being aware of the problem, like I was in early adolescence. Rather, from my teens on, I did realize to some extent that my eating habits weren’t normal. I remember one day buying five candy bars at once and eating them all in one go. When my classmates pointed out that this was outrageous, I shifted from lack of awareness of my eating disorder into denial.

As I said, I stayed in denial for years. I continued buying sausage rolls for lunch every single day until the end of high school, then at blindness rehab ate candy and chips everyday. I gained rougly ten pounds in those four months at blindness rehab, thereby reaching the upper limit of a healthy BMI.

It took several more years before I moved into the stage of anger. By 2008, I was convinced I would die young, and my unhealthy eating habits were one reason for this. I hated myself and my body, yet didn’t stop eating unhealthy amounts of candy. If anything changed at all, I binged more.

I don’t know how I maintained a relatively healthy weight until 2012, but I did. I did start purging in 2011, which can be seen as either a response to anger or a form of bargaining. After all, bargaining can also be seen as trying to reduce the (effects of the) addiction while not completely trying to abandon it.

I reached overweight status in 2012, then obese a few months ago. I started going to a dietician in 2012, then quit going again, went back in the fall of 2013, quit again, and recently started going again. I am still at the stage of bargaining regarding my disordered eating. When told I just need to stop buying candy, I object. Instead, I want to lessen my candy consumption, keep it under control. Yet isn’t the whole point of an addiction not the substance, but the lack of control? I know that one difference between food and alcohol or drugs is that you can’t completely abandon food, and my dietician said that getting fruit or veggies within easy reach as a substitute for candy, is unlikely to work. After all, I’m going to keep the idea that food is an easy way out of emotional stress.

Overeating or Binge Eating Disorder: Is It “Food Addiction”?

I have had issues with disordered eating since early adolescence. I mostly engage in overeating or maybe even binge eating (a binge being a distinct period of severe overeating accompanied by a feeling of being out of control). When I still purged regularly several years ago, I took my eatig issue much more seriously than I do now, despite my overeating/bingeing having gotten worse over time and my weight recently having increased to a number that is within the obese range for my height.

Overeating is often seen as an addiction. I’ve never really seen my eating habits as such, and I wonder what the implications would be if “food addiction” were formally recognized. Curtis & Davis (2014) ask the same question in the conclusion to their qualitative study of “food addiction” in obese women with and without binge eating disorder (BED). In their study, all BED women met criteria for “food addiction” when DSM-5 criteria of substance use disorder were used with food being the substance. Obese women who didn’t suffer from BED also often displayed “food addiction” symptoms. They however attributed their inability to stop overeating more to liking the food or not wanting to stop than to feeling intrinsically unable to stop.

Interestingly, many women in the study weren’t sure whether they were food addicts when directly asked about it. I can relate to this. I at one point participated in an unofficial Overeaters Anonymous online group, and didn’t feel this suit me really. I do notice that I hold many of the same misconceptions about what an addiction is that the study authros found. For example, I tend to believe food cannotbe addictive because we need it, that substance abusers use their substance all the time, etc. The idea of food as an addictive substance does raise questions about what it is to be dependent on a substance. I know that the DSM-5 removed the distinction between substance abuse and substance dependence, and, in a way, this is good. Then again, you can get physically dependent on certain substances, and that makes an addiction to that substance (eg. alcohol) look more real than an addiction to a substance that you won’t develop physical dependence. Addiction to a substance you can’t get physically dpeendnet on, in turn, looks more real than behavioral addictions like “Internet Addiction”. These novel addictive disorder concepts do create fundamental debates about personal responsibility, which do have implications for treatment. After all, an impulse control disorder is treated differently from a substance dependence.

Reference

Curtis C & Davis C (2014), A Qualitative Study of Binge Eating and Obesity From an Addiction Perspective. Eating Disorders: The Journal of Treatment & Prevention, 22(1):19-32. DOI: 10.1080/10640266.2014.857515.