I have stated many times that the key in maintaining long term sobriety is to feel good If one is feeling bad most of the time , it is only a matter of time before they relapse. If some one is angry, jealous, lonely. they will relapse. It does not make a difference if we are justified in our feeling bad; feeling bad causes relapse.
If one is suffering from a psychological disorder, they will be also be feeling bad. The psychological disorders that are most common are depression, anxiety, bipolar disorder as well as ADHD. I will save ADHD to another article
I do not claim to be hugely expert is these problems and I am aware that there are a lot of other sites that review these problems more comprehensively. I only want to review these concepts quickly.
Depression is most common. Up to 50% of woman will be clinically depressed at some point in their lives and a large fraction of men are also afflicted. It is normal to get depressed for a few days at a time, it becomes more relevant when the period lasts for weeks and especially when it last several months.
Most people feel that sad mood is essential for depression. While this is a common symptom, it is not necessary to feel sad when you’re depressed. I feel the most important element is isolation. Things do not interest us; we withdraw from people and activities that use to cause us pleasure. Another common problem is lack of
concentration making it harder to perform at work and school. People often report memory problems; this is a result of the lack of concentration. (These symptoms are also seen in withdrawal during the first few months. The persistence of theses symptoms may be the only way to differentiate between depression and withdrawal).
Sleep disturbance (especially early awakening), weight loss or weight gain, fatigue are also common. People tend to be irritable and, if they are not too withdrawn, tend to bite off your head.
Many different types of medications are available to treat this and many are quite effective. It is interesting that both marijuana and opiates act as anti-depressants; perhaps these are being used by people to treat depression they are unaware they have.
Anxiety comes in many different forms but all involve fearfulness. Often anxiety is mistaken with irritability. If I say hello to an irritable person, they’ll snap at me. If I say hello to an anxious person, they’ll try to run away. The following are subtypes of anxiety:
Generalized Anxiety Disorder chronic level of mild or moderate anxiety
Panic Disorder OK most of the time but episodes of panic and impending doom. People often isolate because they are afraid of losing control
Social Anxiety Disorder Fear of certain situations. It is normal to fear certain situations (such as getting up to speak in a large room) but not getting on a bus. I once had a person who could not urinate except at home or work.
Post Traumatic Stress Disorder This occurs after a scare. It may take months to develop. It is characterized by intrusive thoughts, nightmares and anxiety brought on by various triggers.
Obsessive/Compulsive Disorder Some may not consider this a subset of anxiety. Certain people have highly-structured and ritualistic behavior. They become very anxious if they are forced to stray from their routine.
Traditionally, people with anxiety are treated with sedatives such as Xanax and Valium but the use of these medications is problematic in an addicted population. Luckily a variety of non-habit forming medications are available for use.
Another common problem is bipolar disorder. Patients get depressed at times but also get “manic” at times. Mania can be difficult to discern from addiction since many of the characteristics of this disease is seen at various time related to intoxication or drug-seeking behavior. I try to focus on a time when my patients may have been free of drug use to look for typical behavior.
A manic person feels good; has lots of energy and can often get a lot of things accomplished. Every one wants to be a little manic. However, they may or may not be inefficient at their tasks and are often unable to follow through on what they are trying to accomplish. They are often intense and dismissive of others. They exhibit bad judgment and are more likely to spend too much money, act out, commit inappropriate acts or get into a fight. Concerned friends will often notice the change. One clue is the periodicity of these symptoms: they last from days to weeks or longer and in between they do well.
The problem is twofold. A manic episode is often followed by a period of depression. Also, relapse often occurs; since bad behavior is not perceived as having consequences, returning to drug use also has no consequences.
In all of these disorders- it is important to identify and treats since without treatment relapse is more likely. One word of caution; for many with early onset addiction (before age 25) antidepressants may actually increase dtug use as it increases cravings and impulsive behavior
How many times has the addict wished that they had more self-control and could resist the cravings for the drug? I have stressed that the existence of a craving is the basic abnormality in addiction. The patient is still responsible for their behavior; they are responsible for whether they give in to their cravings. When cravings are extremely intense, almost anyone will give in. Yet, what happens when the cravings are not as intense? The ability to resist cravings in general becomes a factor.
Attention Deficit disorder (ADD), with or without a component of hyperactivity(ADHD) , is a common and often misunderstood problem. I have seen some estimates that 25% of boys can be diagnosed as such. Many girls are similarly affected even if they are less like to exhibit hyperactivity. The majority of people will have their disease last into adulthood. Although many adults have learned to accommodate their weaknesses and tendencies, they are still affected by them
As in many behavioral conditions,, there are some relevant brain abnormalities. People are aware that dopamine is released with drug use. In fact, dopamine is also released when we think pleasurable thoughts and need to stay focused on a goal. It is as if the thought is rewarding and this allows us to concentrate on it more. In ADD, there is a deficit of dopamine in the nucleus accumbens so the thought will slip from our mind. We will therefore have out attention wander all over the place. This may be the most important contributor to ADD.
In addition, this deficit of dopamine in the nucleus accumbens will throw off goal directed behavior (please see article two motivation circuits). This will lead to more impulsive behavior and drugs use.
ADD is considered by many a disease. However, it is not clear to me that ADD is a disease but rather a trait. Some people are faster and some are taller. Some people focus more on a task and some people have their attention all over the place. A million years ago, one of our ancestors who was focused on a task may not have noticed the lion nearby. Therefore, some degree of a wandering attention is healthy. Unfortunately, in our present society, the wandering attention is more of a hindrance than a benefit. It may still need to be treated.
One of the things we learn when we are young (as preschoolers and younger) is how to focus our attention on what we are doing and tune out other things. We all have our attention torn away from the task at hand, but we learn to tune out distractions and come back to it. We resist the impulse to focus on other stimuli in the environment. Therefore, at its’ core, ADD is an impulse control disorder. How can the addict with ADD ignore their drug using impulses if their ability to ignore any impulse is diminished?
Not only that, the inability to filter out and ignore the plentitude of environmental stimuli results in an overwhelming environment for the ADD patient. This creates stress that in turn increases the impulse to use drugs.
ADD does not create the addiction. However, since both problems are common, there are many people who have both. These are the people that are most disabled by their addiction. They are also more like to participate in impulsive, inappropriate behavior to get drugs. They may act out more and be more violent. Such behavior may have legal consequences.
I assume any young person coming to my office has the problem especially if their drug use has been continuous since high school or before. Many times I can get a history that the use of cocaine allows them to focus better.
ADD needs to be differentiated from other psychiatric problems. I often have difficulty distinguishing it from mild forms of manic-depression. Frequently, I refer patients out for objective psychological testing to determine what is going on.
As you can imagine, persons with ADD have a much higher incidence of substance abuse. When they are treated for ADD, the incidence of substance abuse goes down to a level on par with the rest of the population. It is unfair to look at stimulant use since Ritalin is a stimulant. However, the use of alcohol, opiates and other categories of abused substances will decrease.
The treatment has traditionally been Ritalin, Adderall or other types of stimulants. The ADD patient typically becomes quieter and more focused. It’s as if we have stimulated their ability to inhibit themselves. We may be doing this by increasing the dopamine in their nucleus accumbens which , as mentioned earlier, is a cause of this process
These drugs are Category Two drugs and do carry a risk of abuse. I am always hesitant to use them in people who have demonstrated themselves to be unreliable. Yet, if the disease is well documented, and no other interventions have worked, it is reasonable to use these medications with caution. Most do not misuse them; in fact; the incidence of addictive behavior plummets when people are treated
In the past few years, a non-controlled medication named Strattera has become available. It works well and is safer to use. I do prescribe it first line to many patients. Other meds are also available