While determining which disorder is primary in dually diagnosed populations can be useful in clinical research, it may provide little benefit in the clinical management of these patients. Patients with two disorders typically require treatment for both; the exception is patients who present with temporary psychiatric symptoms caused by the substance use or its withdrawal.
Meyer (1986) suggests considering six possible ways in which substance use and other psychopathology may be related:
1. Psychopathology may be a risk factor for SUDs. As described previously, studies of patient and community samples have shown that the risk of having a co-occurring SUD is elevated in persons with psychiatric disorders. For example, dopaminergic dysfunction in patients with schizophrenia has been hypothesized to increase their risk of SUDs—particularly cocaine use disorders (Green et al., 1999; Smelson, Losonczy, Kilker, et al., 2002). Another theory, widely known as the "self-medication hypothesis" (Khantzian, 1989, 1997), suggests that psychopathology leads patients to use substances in an attempt to decrease unwanted psychiatric symptoms. For example, a patient with insomnia due to PTSD nightmares may use alcohol or marijuana to induce sleep. Although research has not found direct connections between particular psychopathologi-cal symptoms and specific substances (rather, patients tend to misuse a wide variety of substances to "treat" a range of symptoms), the general principle is an important one. It is discussed in more detail in the next section.
2. Psychiatric disorders and co-occurring SUDs may serve to modify the course of each other in terms of symptomatology, rapidity of onset, and response to treatment. Also described earlier, there is considerable evidence that comorbidity is associated with worse outcomes. Additionally, there is evidence that patients with schizophrenia and co-occurring SUDs do not respond as well as those without SUDs to similar doses of first-generation antipsychotic medications (Bowers et al., 1990).
3. Psychiatric symptoms may result from chronic intoxication. Drug and alcohol use can result in a variety of psychiatric symptoms, such as depression, anxiety, euphoria, psychosis, and dissociative states. Most such symptoms disappear, however, within hours (e.g., cocaine-induced paranoia) (Satel, Southwick, & Gawin, 1991) to weeks (e.g., alcohol-induced anxiety or depression) (Brown, Irwin, & Schuckit, 1991; Brown & Schuckit, 1988).
4. Long-term substance use can lead to psychiatric disorders that may not remit. Alcohol-induced long-term cognitive changes, such as those seen in alcohol-induced persisting dementia, exemplify one way in which chronic use of a substance can create enduring change.
5. Substance abuse and psychopathological symptoms may be meaningfully linked. Some individuals may use alcohol or drugs in ways that enhance their psychiatric symptoms. For example, patients with ASPD may use alcohol or cocaine, seeking disinhibition and aggression, and patients with bipolar disorder may use cocaine or other stimulants to augment a euphoric mood (Weiss, 1986l; Weiss et al., 1988).
6. The SUD and psychiatric disorder are unrelated. The presence of two disorders within an individual does not imply a causal link. For example, both alcohol dependence and depressive disorders are common in the general population; many people with both disorders are not depressed because they drink, nor do they drink because they are depressed. Brunette, Mueser, Xie, and Drake (1997) studied the relationship between severity of substance abuse and severity of schizophrenic symptoms in patients dually diagnosed with both disorders, and found weak relationships and no consistent patterns of relationships between the two sets of symptoms.
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