Psychosis And Substance Abuse

Introduction 

Psychosis refers to a mental state in which a person’s perception of reality is distorted. They may see or hear things that are not there, believe things that are not true, have a significant change in mood, or speak incoherently, in a way that does not make sense.

Psychosis is a feature of some psychiatric conditions such as schizophrenia, bipolar disorder and some neurological conditions including Parkinson’s and dementia. However, people without any underlying diagnosis can experience psychosis too.

Substance abuse refers to an unhealthy use of a drug, perhaps as part of an addiction, which is harmful to the person taking it. The drug can be licit, such as alcohol, nicotine, a prescription medication, or over-the-counter medication. They can also be illicit substances such as cocaine, heroin or methamphetamines. 

Psychosis and substance abuse are very much linked– around 40% of people who experience psychosis also have problems with substance abuse.² This subject is quite broad and varied, so this article will only serve as a brief overview. 

Symptoms of psychosis

One hallmark feature to indicate that someone is in psychosis is hallucinations. Hallucinations involve experiencing something that is not there in reality. This can be visual hallucinations (seeing things that are not there), auditory (hearing), tactile (touch), olfactory (smelling) or gustatory (tasting). 

It is important to distinguish hallucinations from imagination – for example, having a noise in your head, or thinking you have heard something but not being sure of it can just be part of imagination and not necessarily a hallucination. An auditory hallucination involves actually hearing something that sounds like it’s coming from an external source, other than your own head.

In popular media, this has been portrayed as hearing commands of voices telling them to harm themselves or harm someone else. Likewise, a visual hallucination isn’t something the patient is just imagining, or seeing with their mind’s eye – this person is actually seeing it with their eyes. 

The second hallmark feature of psychosis are delusions. Delusions are falsely held beliefs, even in the light of evidence to prove otherwise. In popular media, one way this has been portrayed is that people may believe that the TV is sending them subliminal messages, although this is just an example.¹

Delusions and hallucinations are known as “positive” symptoms because they add something that wasn’t there before (not ‘positive’ in the sense that they are good, or helpful). 

Other symptoms of psychosis, which are not necessarily unique to being psychotic but can and often do present, include: 

• Altered sleep patterns
• Disorganised speech (meaning nonsensical speech that does not make sense to the person hearing. This is also called a “cognitive symptom”) 
• Altered mood e.g. becoming manic or depressed. Person experiencing psychosis may also become very paranoid
• Negative symptoms – these are as opposed to the positive symptoms. Negative symptoms are when something is taken away – like withdrawing from social interactions, neglect of self-care, or lack of energy

Substance abuse (substance misuse)

This is a broad term that refers to people who harmfully use any psychotropic substance. Psychotropic means that they have some way of altering the function of someone’s brain, which may manifest as a change in behaviour, mood, thought patterns, and perception of reality. They may also become addicted or dependent on the substance. 

Examples of psychotropic substances include nicotine, alcohol, certain prescription medications (common examples are benzodiazepines, opioids such as fentanyl), illicit substances such as marijuana (although this is legal in some parts of the world), methamphetamines, cocaine, and heroin. Ketamines which are used for animals can be misused in humans too.⁶

Substance abuse and psychosis 

Substance abuse and psychosis are often found together – this can also be termed as a ‘comorbidity’. The rate of having a substance abuse problem is around three to five times higher in those who experience psychosis as compared to the general population.

Homelessness, lack of response to treatment, relapse, and premature death are all more prevalent in this part of the population.³ Those with a pre-existing psychiatric condition, such as schizophrenia, have a notably worse outcome for their schizophrenia if they are also misusing a substance.⁵

However, other physical health issues such as cardiovascular (heart), respiratory (lung), renal (kidney), or neurological (brain and nerves) diseases also have an increased susceptibility to substance misuse. Conversely, misusing substances can cause dysfunction for many systems of the body, or even cause death.⁷

Substance-induced psychosis 

There is a growing amount of evidence that suggest that some substances do cause psychosis. The rate occurance is around 30%, and more likely to happen the younger the person is at the time of taking the substance. Examples of these include methamphetamines, cocaine, and cannabis. The psychotic episodes are usually acute onset (come on suddenly). Sometimes, these effects are wanted, if the drug is taken intentionally.³

Bi-directional relationship 

The reasons for the strong link between psychosis and substance abuse are complex– those who experience psychosis are more likely to misuse substances. Conversely, those who have substance addictions often go on to meet the diagnostic criteria for illnesses like schizophrenia, even if they did not have any symptoms before their addiction.⁶

However, some research shows that considering the two as separate entities may be an oversimplification, as there are many other factors in a person’s life that should be considered too. 

Biological factors 

The physiological reasons for psychosis and substance abuse are mostly attributed to neurotransmitters, which are chemicals within the brain and nervous system which send messages from one nerve to another. One in particular, called dopamine, is involved in happiness and reward. An excess amount of dopamine can lead to the positive symptoms of psychosis.

Amphetamines work on the dopamine receptors in the brain. The increase of dopamine causes the levels of another neurotransmitter, glutamate, to increase also. This has been attributed to the cognitive symptoms of psychosis. Other neurotransmitters called GABA and serotonin have also been found to be in use of ketamines, LSD and MDMA.⁶

There is a class of drugs given to those with psychotic symptoms (usually if there is already a psychiatric diagnosis like schizophrenia) called ‘atypical antipsychotics’, or neuroleptics. These drugs target the receptors of dopamine, GABA and/or serotonin in the brain to reduce the positive symptoms of psychosis (this is as opposed to ‘typical’ antipsychotics which target dopamine only). Examples of these include quetiapine and olanzapine which can also help with the negative and cognitive symptoms of psychosis.⁶

Genetics also has a part to play. Those with a family history of bipolar disorder or schizophrenia are much more likely to get it themselves. There may also be a genetic component towards susceptibility towards substance addictions. However, there does need to be more research to prove the specific genetic links between them.⁴

Psychosocial factors 

Another major contributor to substance addiction is the psychosocial aspect. Early childhood trauma or stressful situations may make a person more susceptible. Also, due to the physiological changes that happen during psychosis, people may want to escape their symptoms, even if just temporarily. 

A large part of both psychosis (especially as part of a psychiatric condition like schizophrenia or bipolar) and substance abuse is the stigma that is associated with either one of them. Those in these situations can incur consequent problems like being ostracised from their support network of people, perhaps struggling to keep employment or even becoming homeless. This can make them more likely to be marginalised from society, which can result in a dangerous downhill spiral. 

Problems with the law

Those with psychosis and substance abuse problems can often be found either in prison or having previously served time. Substance use is the most commonly occurring factor associated with violence, neglect and other criminal activities. In 1993, the National Institute for Drug Abuse in the US found that more than half of violent crimes involve some form of substance misuse.⁵

As mentioned previously, some drugs are illicit or obtained illicitly – this may be a reason for legal repercussions. Those actively in psychosis may engage in impulsive behaviour that may put their own life or the lives of others at risk. They can be subsequently incarcerated for their actions, and may not receive adequate support for an underlying mental health issue.⁵ 

Summary 

Psychosis is a state of mind in which a person may experience delusions, hallucinations, disorganised speech, severe changes of mood, or withdrawal from life activities. Psychosis is a feature of some psychiatric illnesses such as schizophrenia and bipolar disorder.

Those who experience psychosis are more susceptible to substance misuse, and those who misuse substances are more likely to experience psychosis. There are many factors involved, including physiological changes associated with psychosis itself and the drugs taken, psychosocial factors such as having a substance addiction or a psychiatric illness, and genetic factors.