Co-Occurring Psychotic Disorders and Substance Use Disorders
When a person’s thoughts and perceptions are disrupted in ways that make it challenging for them to discern what’s real or not, they could be experiencing psychosis.1 People who experience periods of certain characteristic cognitive disturbances or problematic thinking are said to be in the midst of a psychotic episode.2
Psychotic disorders are a specific type of mental illness that are often misunderstood and can be frightening and confusing for people who experience them.1 Two key features of psychotic conditions are:3,17
- Delusions—fixed, abnormal, and sometimes bizarre false beliefs.
- Hallucinations—perceptual events that arise without an external stimulus prompting them (i.e., hearing or seeing things that are not real).
While psychosis can sometimes result in connection with substance abuse, this is not always the case. Some people with substance use problems might have a psychotic disorder that is entirely independent of their substance abuse. In these instances, a person is said to have a co-occurring mental health and substance use disorder (SUD).
Learn more about this dual diagnosis and how effective treatment can help to manage symptoms of both and help you or a loved one work toward long-term recovery from drug and/or alcohol addiction.
What are Psychotic Disorders?
Psychosis is a feature of several types of mental disorders—including schizophrenia and some forms of bipolar disorder—in which a person loses touch with reality and perceives the world in different ways than non-affected individuals.3
Some people who have psychosis will also display disorganized speech and are not easily understood by others.2 In certain cases, acute psychotic episodes can result from the use of alcohol or drugs.1 Other factors associated with psychosis include a genetic predilection to the condition; previous exposure to traumatic events; medical issues such as brain injury, brain tumors, HIV, Parkinson’s disease, Alzheimer’s disease, and other forms of dementia; and other mental health issues such as depression.1
Roughly 100,000 people in the United States experience psychosis every year. It has been estimated that as many as 3 in 300 people will experience a psychotic episode at some point in their lives.1
What is Schizophrenia?
Schizophrenia is a complex, long-term mental disorder that affects around 20 million people worldwide and from 0.25% to 0.64% of U.S. adults.4,5 Often, schizophrenia begins in the late 20s to early 30s for women and late teens to early 20s for men, though it may develop in both children and older adults.5
It is characterized by delusions, hallucinations, disorganized behavior or speech and negative symptoms such as diminished emotional expression, anhedonia (i.e., diminished ability to experience pleasure), and avolition (i.e., decreased motivation for goal-directed behavior).4,5
In many cases, it’s difficult to pinpoint a singular “cause” for schizophrenia. Some people have a family history and genetic predisposition to the disorder, but this doesn’t mean that they will necessarily develop the disease.1 As with many types of disorders, genetics, individual characteristics, environment, and substance abuse play a role in the development of schizophrenia.1
The use of certain drugs such as LSD or amphetamines can also cause symptoms in some users that can mimic schizophrenia.5 A person must have several symptoms of schizophrenia for at least 6 months to be diagnosed with the disorder.5
While schizophrenia can be treated, it is not curable. However, the symptoms of schizophrenia can be reduced with medication, psychosocial rehabilitation, and family support.5 There is sometimes a lack of awareness in those who have schizophrenia, which can complicate its initial diagnosis and treatment.5
Early detection can be important though, as it may help to decrease the frequency of recurring psychotic episodes, reduce the severity of symptoms, and improve the overall long-term management of the condition.5
What is a Substance Use Disorder?
Addiction entails a chronic, compulsive pattern of substance use that continues despite the negative consequences resulting from such use.6 People who struggle with addiction to drugs and/or alcohol are sometimes diagnosed as having a substance use disorder.
According to the National Survey on Drug Use and Health, approximately 20.3 million Americans had a substance use disorder in 2018.7 Of them, roughly 15 million struggled with alcoholism, or alcohol use disorder, and more than 8 million had issues with drug addiction, or an illicit drug use disorder.7 Further, an estimated 2.7 million people had a substance use disorder involving both alcohol and illicit drugs.7
To be diagnosed with a substance use disorder, a person must within the past 12 months exhibit at least 2 of 11 specific criteria outlined by The Diagnostic and Statistical Manual of Mental Health (DSM-5). Such criteria include items such as prior failed attempts at cutting back on substance use, an increased amount of time spent obtaining and using substances, the arrival of withdrawal symptoms when substance use slows or stops, and other disruptions to an individual’s life. Substance use disorders are treatable yet chronic, and often-relapsing conditions.6
Treatment typically consists of a combination of therapeutic approaches, including behavioral therapy and medication.6 Such a strategy may be most effective when the individual treatment elements are tailored to a person’s specific needs.8
Co-occurring SUD and Psychotic Disorders
Oftentimes, it is difficult to know which came first—the substance abuse or the psychotic disorder. In some instances, some individuals may already be abusing drugs and/or alcohol prior to experiencing their first psychotic episode. While others may self-medicate with drugs or alcohol to cope with depression, anxiety, or other mental health issues which may itself lead to a psychotic episode.9
For some, using substances may trigger the onset of psychosis, which might only manifest when the person is actively abusing a substance. In these instances, an individual may not be diagnosed with a co-occurring disorder, as a person should be experiencing a psychotic illness separate from using substances to technically be diagnosed with a co-occurring disorder.10
However, regardless of which was present first, it is well established that substance misuse greatly affects those with psychotic disorders and results in a more prolonged and serious condition.9 An integrated approach to treatment which addresses both disorders is necessary to promote better outcomes.11
Adverse Consequences of Substance Use
Alcohol, cocaine, cannabis and other psychostimulants are among the most commonly abused substances by people with schizophrenia.10 Evidence suggests that substance use can exacerbate symptoms of psychosis, provoke relapse, and result in generally poorer outcomes than in those with psychosis alone.9
One review study took a look at people with first-episode psychosis and found that around 50% of those who experienced their psychotic episode already had a substance use disorder.12 Another article in the field points to a potential increased risk of substance misuse in those taking antipsychotic medication to treat psychosis.9 Since these medications work by blocking dopamine receptors in the brain, and therefore may affect our brain reward centers, it’s theorized that some people may attempt to override this effect by using substances.9
Additionally, people who have both psychosis and a substance use disorder may be much more likely to be incarcerated, drop out of treatment, fail to adhere to a treatment plan, and be hospitalized than those with psychosis alone.12 Studies suggest that individuals with psychosis and coexisting substance misuse may also experience increased levels of morbidity (e.g., poorer physical health) and higher incidences of premature mortality.9
Schizophrenia and Drugs and Alcohol Use
In individuals struggling with schizophrenia, alcohol and marijuana use occurs at about 3 times the rate of those without the disorder.11 A number of theories have been examined as way to understand why a co-occurrence of schizophrenia and substance use such as this is so prevalent.
One idea is that people who go on to develop schizophrenia may have an innate vulnerability to the condition, such that the use of certain substances combined with this vulnerability may lead to the onset of or relapse of psychosis.11 Another theory is that people with schizophrenia use alcohol and/or drugs to self-medicate in an effort to reduce their symptoms or to dampen the side effects of treatment drugs for the psychotic disorder.11
Treatment for Substance Abuse and Psychotic Disorders
Research has demonstrated that an integrated approach to treatment is the most effective way to treat co-occurring disorders.9 As part of this, patients can benefit from receiving the same messaging in their programming from their therapeutic treatment teams in order to better understand their mental illness and substance use.11
Programs that coordinate substance abuse counseling, pharmacotherapy, and psychosocial treatments with a comprehensive treatment program may be more likely to effect better outcomes in those they treat.11 Integrated treatment approaches for both substance use and mental health disorders may include medication management, rehabilitation, social support, and long-term aftercare planning to prevent replase.11
Detox and Withdrawal
At the start of treatment for substance use disorders, patients will commonly first undergo a medical detox to manage their withdrawal from drugs and/or alcohol. In individuals who’ve developed significant physical dependence to certain substances, symptoms of acute withdrawal may occur.13
At times these symptoms may be severely unpleasant and potentially life-threatening, such as in cases of benzodiazepine or alcohol dependence.13,14 Proper medical management can help individuals stay as safe and comfortable as possible while detoxing.15
Inpatient and Outpatient Rehab
Though a period of detox is commonly incorporated into longer-term residential treatment programs, it won’t necessarily always be this way. In such instances, after withdrawal has been successfully managed, recommendations may be made by your treatment team whether an inpatient or outpatient treatment setting will be best to continue work toward recovery.
A comprehensive recovery program for co-occurring substance abuse and psychotic disorders may incorporate several levels of care and treatment modalities including private and group therapy, family counseling, behavioral therapies, medications, and aftercare planning.15
Certain types of behavioral therapy approaches, such as motivational interviewing, may be used effectively to manage both psychosis and substance use disorders. Cognitive behavioral therapy is also effective in addressing the negative thinking patterns found in both types of disorders and helping the person cope with problems and stressors in a new way.9
For certain types of substance use disorders, ongoing medication-assisted treatment may be beneficial, such as buprenorphine or methadone for opioid addiction.16 Such treatment medications may be combined with a variety of antipsychotic drugs to simultaneously manage the co-occurrence of psychosis and addiction issues. Additional pharmacologic and medical interventions may be administered to address any nutritional deficiencies and physical illnesses present, as these are quite prevalent in this patient population.9
How to Get Help Now
If you’re ready to seek treatment for a co-occurring psychotic disorder and drugs and/or alcohol addiction, American Addiction Centers (AAC) is ready to help you get the help you need. AAC is a leading provider of addiction treatment services with several facilities nationwide.
Our approach to treating substance abuse and co-occurring mental health issues is founded in evidence-based treatments and proven therapies while offering unique services to meet your individual needs. Call our 24/7 hotline today to speak with one of our friendly admissions navigators to learn more about your treatment options. All calls are confidential.
Each person who walks through our doors is important to us. You deserve the highest quality of treatment—marked by clinical excellence, individualized care, and a supportive community—and we’re ready to help guide you toward recovery, every step of the way.
1. National Alliance on Mental Illness. (2020). Psychosis.
2. National Institute on Mental Health. (n.d.). What is Psychosis?
3. MedlinePlus. (2020) Psychotic disorders.
4. World Health Organization. (2019). Schizophrenia.
5. National Alliance on Mental Illness. (2020). Schizophrenia.
6. National Institute on Drug Abuse. (2018). The Science of Drug Use and Addiction: The Basics.
7. Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). The National Survey on Drug Use and Health: 2018.
8. National Institute on Drug Abuse. (2018). The science of drug use and addiction: The basics.
9. National Collaborating Centre for Mental Health (UK). (2011). Psychosis with coexisting substance misuse: Assessment and management in adults and young people. Leicester (UK): British Psychological Society.
10. Caton, C.L., Samet, S., & Hasin, D.S. (2000). When acute-stage psychosis and substance use co-occur: Differentiating substance-induced and primary psychotic disorders. Journal of Psychiatric Practice, 6(5), pp.256-266.
11. Green, A. I., Drake, R. E., Brunette, M. F., & Noordsy, D. L. (2007). Schizophrenia and co-occurring substance use disorder. American Journal of Psychiatry, 164(3), 402-408.
12. Wisdom, J. P., Manuel, J. I., & Drake, R. E. (2011). Substance use disorder among people with first-episode psychosis: a systematic review of course and treatment. Psychiatric services, 62(9), 1007–1012.
13. UpToDate. (2020). Management of moderate and severe alcohol withdrawal syndromes.
14. U.S. National Library of Medicine. (1994). The benzodiazepine withdrawal syndrome. Addiction;89(11):1455-9.
15. Substance Abuse and Mental Health Services Administration. (2006). Detoxification and Substance Abuse. Treatment Improvement Protocol. (TIP) Series, No. 45. HHS Publication No. (SMA) 15-4131.
16. Douaihy, A. B., Kelly, T. M., & Sullivan, C. (2013). Medications for substance use disorders. Social work in public health, 28(3-4), 264–278.
17. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Am