1. Schizophrenia and Substance Use Disorders
How do Thought Disorders and Substance Use Disorders Interact?

2. Topic Areas I. Description of Thought Disorders
II. Influential Factors on the Illness
III. Effect of Substance Use
IV. Implications for Recovery

3. Description
of Thought Disorders

4. How is it decided
if someone has a
“thought disorder?”

5. Diagnostic Criteria for Schizophrenia*
A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period:
(1) delusions
(2) hallucinations
(3) disorganized speech
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, i.e., affective flattening, alogia, or avolition
B. Social/occupational dysfunction: One or more areas of functioning such as work, interpersonal relations, or self care are markedly below the level achieved prior to the onset.
C. Duration: Continuous signs of the disturbance persist for at least 6 months.
E. The disturbance is not due to the direct physiological effects of a substance or a general medical condition.
* Diagnostic and Statistical Manual, 4th Ed. (2000). American Psychiatric Association. Arlington, VA. p. 312

6. Diagnostic Criteria for Schizoaffective Disorder*
A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.
B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
C. The disturbance is not due to the direct physiological effects of a substance, or a general medical condition
* Diagnostic and Statistical Manual, 4th Ed. (2000). American Psychiatric Association. Arlington, VA. p. 323

7. Diagnostic Criteria for Substance-Induced Psychotic Disorder*
A. Prominent hallucinations or delusions.
B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
(1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal
(2) medication use is etiologically related to the disturbance
D. The disturbance is not better accounted for by a Psychotic Disorder that is not substance-induced.
* Diagnostic and Statistical Manual, 4th Ed. (2000). American Psychiatric Association. Arlington, VA. p. 342

8. Terms and Definitions
“Positive” symptoms (“in addition to” what was experienced before the illness) include;
Delusions
Hallucinations (Auditory, Visual, etc.)
Disorganized Speech
Bizarre Behavior

9. Terms and Definitions
“Negative” symptoms (“taken away from” what was experienced before the illness) include;
Alogia
Affective Blunting or Flattening
Avolition
Anhedonia
Attentional Impairment

10. Delusions False beliefs Affects the “Inference” system of the brain
(ex.) “Conspiracy theories” are common

11. Hallucinations False perception
Affect the “Perception” system of the brain
Auditory hallucinations are most common
Any of the 5 senses may be involved

12. Disorganized Speech Affects the “Language” system of the brain
(ex.) Word salad is a jumble of words/phrases that lacks comprehensible meaning;
(ex.) Tangentiality is a style of speech in which a person replies to questions in an irrelevant, “off the topic” manner).

13. Bizarre Behavior Affects the “Behavior-inducing” systems of the brain
(ex.) Ritualistic behaviors – may represent “normal” responses to the “abnormal” stimuli of active delusions or hallucinations

14. Alogia
the inability to organize one’s thoughts and express them fluently

15. Affective Blunting or Flattening
“Flat affect”
A deficiency in the ability to express a full range of emotion
May be expressed in a monotonal voice, a “poker face,” or a “schizophrenic stare”

16. Avolition The inability to initiate a behavior, or carry it out
(exs.) Withdrawal, apathy, decreased energy, decreased motivation

17. Anhedonia The inability to experience pleasure or enjoyment
May result in the discontinuation of hobbies or recreational activities

18. Attentional Impairment
Difficulty in focusing attention
Can lead to inability to complete tasks or activities that require focused attention

19. II. Influential Factors

20. Family History (Genetic) Factors
Individuals with schizophrenia are more likely to have relatives with psychiatric illness (or substance use disorders)
Indicates a genetic vulnerability to psychiatric illness (and substance use disorders)

21. Supersensitivity Model
Biological vulnerability + environmental stress = precipitate the onset of the disorder or trigger relapses
Medications decrease vulnerability
Substance use increases vulnerability

22. III. Effect of Substance Use

23. Alcohol Use
Combining Alcohol and antipsychotic medication can cause life-threatening oversedation

24. Cocaine Use
Cocaine abuse can damage the brain and cause psychotic episodes to occur

25. Marijuana Use
Marijuana use can contribute to the frequency and intensity of psychotic episodes
More severe positive symptoms
Quicker psychiatric relapses & re-hospitalizations
Earlier age of onset

26. IV. Implications for Recovery

27. Special Considerations
More likely to develop addiction with recreational use.
Many clients report using substances to facilitate social interactions with peers.

28. Principles of Integrated Treatment*
Integration
Comprehensiveness
Assertiveness
Reduction of Negative Consequences
Long-Term Perspective
Motivation-Based Treatment
Multiple psychotherapeutic modalities
* Mueser, K.T. et al. (2003). Integrated Treatment for Dual Disorders. Guilford Press: Canada. p