The self-medication hypothesis in schizophrenia: what is it and what does it propose?

The self-medication hypothesis in schizophrenia explains the use of drugs in schizophrenia.

One of the most resonant facts in clinical psychology and psychiatry is that patients with schizophrenia usually present very high rates of addiction. Practically half of them consume some psychostimulant substance, either coffee and tobacco in large quantities or dangerous drugs such as cocaine.

Attempts have been made to explain why this phenomenon occurs, one of the most frequently used explanations being the self-medication hypothesis, originally put forward to explain drug dependence "pure and simple" but which has been of great importance in explaining these substance disorders in other mental disorders.

Today we will explore in depth the self-medication hypothesis in schizophreniaWe are trying to understand the link between this disorder and the consumption of illicit substances. Here we go!

What is the self-medication hypothesis in schizophrenia?

Substance abuse is a presenting problem that is highly comorbid in schizophrenia. It is estimated that about 50% of people diagnosed with schizophrenia have some form of substance abuse, a very high percentage compared to those diagnosed with schizophrenia.This is a very high percentage compared to the 15% in the general population who have addictions or have had them in the past. In other words, patients with schizophrenia are up to 4.5 times more likely to have an addiction.

Any drug can be the drug of choice for this type of patient. In the most severe cases, patients with schizophrenia abuse illicit drugs such as amphetamines, cocaine or cannabis. and, in the mildest cases, they are usually heavy smokers and consume large quantities of coffee or other psychostimulant beverages.

Several factors have been proposed and identified as the mechanisms and determinants behind the high comorbidity between addiction and schizophrenia. These include social and family aspects, such as family vulnerability, living in an economically depressed environment, having suffered some type of abuse; genetic, such as hereditary predisposition and history of addictions within the family; and problems related to the medications used to treat schizophrenia, especially the side effects.

Many explanations have been put forward to better understand the link between schizophrenia and addiction. Among them stands out the self-medication hypothesis, one of the most influential and resonant proposals to explain the relationship between schizophrenia and addictions, and also extrapolating it to other disorders such as anxiety, depression or bipolar disorder.

Key ideas of the self-medication hypothesis.

Although this approach remains what it is, a hypothesis, and therefore still pending to be fully demonstrated, the self-medication hypothesis is a set of ideas widely spread and accepted among psychologists and psychiatrists, having its origins in the work of Khantzian's group (1985; 1997) and that of Duncan (1970s). Within this hypothesis, applied to addictions in general terms, we can highlight the following four approaches.

1. Existence of neurological dysfunction

One of the explanations behind the appearance of an addiction would be the existence of a neurological dysfunction, of genetic or acquired origin, in the neuromodulation-neurotransmission systems at the level of the central nervous system (CNS). (CNS). This alteration would give rise to an alteration in the regulation of the processes of analgesia, psychic and organic homeostasis, sexual response, affective life and higher cognitive activity, among others.

The patient affected by such dysfunction would suffer from a set of psycho-organic discomforts, which would cause a notorious decrease in his quality of life. This person, whose addictive disorder would have an obvious biological cause, in case of encountering psychoactive substances, could initiate a rapid process of dependence if he/she were to become addicted to them, could initiate a rapid process of dependence if such substances act as a sort of highly "effective" medication for the disorder he/she suffers.at least in the short term and as he or she sees fit.

It may be that his or her organic dysfunction is solved spontaneously or by pharmacological means but, if this is not the case, this approach maintains that the specific relapse prevention treatments would be doomed to failure, since sooner or later the patient would return to seek that solution which, although toxic, he or she considers useful and effective to solve the problems caused by his or her brain dysfunction.

2. Biological vulnerability

Another of the ideas defended within the hypothesis of self-medication would be a variant of the first one, but in this case the cerebral dysfunction would not be due to any genetic problem or because of an acquired lesion, but it would be due to the existence of a special vulnerability of their neuromodulation-neurotransmitter systems to psychoactive substances..

Thus, the use of drugs would generate functional alterations that would dysregulate nervous stability, causing psychological problems in the individual who consumes them. In this case, if psychology and psychiatry do not provide a solution to the problem, the patient would be forced to perpetuate drug use in an attempt to try to establish his or her life.

3. Existence of predisposing factors

A third sub-hypothesis is that there are predisposing factors to the onset and maintenance of drug dependence, which would be the presence of psychological disorders at the onset of addictive behavior. Considering that many illicit drugs have antipsychotic, Antidepressant and anxiolytic (short-term) effects, the self-medication hypothesis suggests that patients with drug dependencies may actually be patients with other psychiatric conditions who self-medicate, with relative success.

These patients find it very difficult to achieve and maintain abstinence after detoxification, due to incomplete therapeutic action.These patients find it very difficult to achieve and maintain abstinence after detoxification, due to the incomplete therapeutic action and troublesome adverse effects of the drugs they are prescribed. Among these drugs are neuroleptics, antidepressants and anxiolytics, whose side effects motivate the consumption of drugs to counteract their effect. It would be this explanation in particular that would explain the self-medication carried out by patients with schizophrenia.

4. Disorders as a consequence of addiction

The fourth explanation within this hypothesis is a variant of the third, and proposes that mental disorders would be a consequence of the consumption of psychoactive substances.

In other words, there would be patients with no previous psychiatric pathology who are vulnerable to the psychotropic effect of drugs, which would cause them to develop serious mental disorders of long duration and difficult remission. Once the substance-induced psychopathological picture has been established, the patient may present with compulsive drug use in an attempt to contain the symptomatology..

Its application to a pathology such as schizophrenia

According to the self-medication hypothesis in schizophrenia, people with this disorder end up abusing drugs as a consequence of their disorder, in the sense that they take psychostimulant substances to manage negative emotions and other problems typical of schizophrenia.

Basically, this hypothesis argues that the patient does not take drugs to feel euphoric and happy, but to reduce dysphoria and distraction. to reduce the dysphoria and distress ("bad emotions") he suffers from, and since he does not know of a better way to do this.and since he does not know of a better way to improve his symptoms, he chooses to consume illicit and toxic substances.

It would also explain why patients with schizophrenia, despite already being treated, turn to other addictive substances. The reason for this would be that drugs would be taken to try to combat the side effects of antipsychotic drugs, such as dysphoric responses or extrapyramidal symptoms.

This hypothesis of self-medication in schizophrenia gained much prominence in the late 1980s. gained much prominence in the late 1980s, although its antecedents are to be found in various psychoanalytic formulations proposed during the 1950s.although its antecedents are to be found in several psychoanalytic formulations proposed during the 1950s. At that time it was already suggested that drugs were used as a coping mechanism against psychotic aggressive tendencies and negative emotions not only in psychotic disorders, but also in people who might appear to have other disorders with depressive and anxious symptomatology.

Relevance of the hypothesis

In general terms, the self-medication hypothesis is a formulation, a working hypothesis that allows us to combat the widespread, deep-rooted and erroneous belief that drug dependence is merely a "vice", a problem in the patient's personality and temperament or some failure in his or her environment that has caused him or her to take up an addiction, such as alcohol, cannabis or cocaine.

The self-medication hypothesis, applied in schizophrenia as in any other disorder, exculpates the patient, his family and his environment.. Here the "blame" does not fall on parental styles or personality traits, which may have played a role in the development and maintenance of an addiction, but more importance is given to the fact that drugs are sought to reduce symptoms of mental disorders or brain injuries, and the weight of the possible hedonistic pleasure that the user may be trying to satisfy is underestimated.

Although it remains a hypothesis and is therefore a formulation yet to be fully demonstrated, it has been truly useful in addressing substance abuse. In one way or another, the self-medication hypothesis has helped to de-stigmatize substance abuse. has contributed to de-stigmatize drug dependence, with the understanding that addicts are not addicted to drugs.It is understood that people addicted to substances are not addicted because of "temperamental weakness" or "lack of values", but that they use drugs as a means of coping with their problems.

When we meet someone who is addicted, instead of asking ourselves what the person has done wrong or what bad influences he or she may have received to fall into addiction, what we should ask ourselves is the role that the drug has in his or her life. We should find out what the substance brings him/her, what problem it "solves" every time he/she consumes it. Once this is done, a substitute for that harmful substance should be sought, in addition to teaching the patient healthy and effective methods to cope with his psychological distress, whether it is due to schizophrenia or another mental disorder. This is the only way to break the addictive cycle.