Above, Papaver somniferum and its derivative heroin, below the coca plant and cocaine

Two types: primary and secondary

Addictions come in two basic types:  those which exist independent of other psychiatric conditions, and those additions which are caused by other psychiatric conditions.  The first kind can improve with addictive behavior treatment, such as 12-step approaches.  The second kind can also improve that way, but is more likely to improve if the underlying psychiatric illnesses which cause or promote addictive behaviors are treated.

In other words, the concept of  a diagnostic hierarchy is again relevant, as explained here. If the addictive behavior happen as part of other illnesses, then it is not itself a separate illness necessarily.  (Just as fever occurring with pneumonia is not a separate fever “disorder”).

Secondary addictions

The most common psychiatric disease that causes addictive behaviors is bipolar illness (60% also have addictions), followed by severe unipolar depression (40% have it), and then anxiety conditions and schizophrenia. 

Since many addictive drugs can cause depressive symptoms, or anxiety, or even psychosis, the key treatment question is whether patients should be treated by 12-step approaches and/or rehabilitation counseling alone, or combined with medications for their psychological symptoms. 

Coexistence with depression/bipolar: To treat or not to treat?

The PL approach is that if mania or psychosis is present, patients should be treated with mood-stabilizing agents, as in the treatment of bipolar illness.  This is because few addictive agents cause mania (in contrast to many which cause depression or anxiety). Of those agents which cause mania (like cocaine or amphetamines), it is difficult to defend the view that bipolar symptoms are solely secondary to the addictive behavior unless every single manic episode is immediately preceded by cocaine or amphetamine use, and no drug use happens at any other time when manic episodes are not present.  This course is rarely the case.  So we recommend that mania always be treated with mood stabilizers, whether addictive behaviors are present or not.  Usually, those patients have addictive behavior secondary to bipolar disease, rather than the reverse.

If depression or anxiety is present, we take the opposite approach: we do not recommend that antidepressants and benzodiazepines be used routinely for depressive and anxiety symptoms in the presence of addiction. Sometimes a separate depressive or anxiety disease may be present, in which case those agents may be needed, but this should not be assumed routinely in most patients. How can a clinician figure this out?  We suggest that dependence treatments be given initially for some amount of time, without antidepressants or anxiolytic treatments; if there is no progress after sufficient time (which depends also on patient compliance; in the best case scenario, 6 months or more of addictive behavior treatment would seem rational), then antidepressant or anxiolytic treatment can begin.

Primary addictions

It certainly is the case that whatever the cause, addictive behaviors can take on a life of their own; the persons becomes addicted, meaning their brain changes, with dopamine system involvement, such that even if the underlying cause is removed (e.g., their bipolar disease is treated to remission), they may still remain addicted, especially to drugs like heroin or cocaine.  In those cases, specific addictive behaviour treatment should be given along with medications for bipolar disease.  It is our experience, however, that many people who have bipolar disease and alcoholism or other drug abuse experience remission of their compulsion when their bipolar disease is effectively treated, without necessarily needing formal addictive behavior treatments (such as 12-step groups). 

The most effective direct treatments for addictive behavior are 12-step programs and individual substance abuse-specific counseling.  Specific medication treatments for narcotic dependence exist, such as naltrexone and gabapentin, but they are modestly helpful at best. 

Other “addictions” than street drugs or alcohol, like sexual compulsions (paraphilias), internet, cellphone, and food compulsions can be seen as primary addictions, and directly treated with variations on 12-step programs.  But this judgment that they are primary should only be made after treatable secondary causes, most importantly bipolar disease or psychotic illnesses, are ruled out, and sufficiently treated first if present.    

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