July - 1999

I think the following deserves serious consideration. We cannot afford to dismiss ideas that might help us clarify what schizophrenia is and some of the etiological possibilities. I encourage the reader to pay attention to the following and if interested, it is possible to contact the writer.

Jack Rosberg

by Norman Jay Gersabeck, MD

I have made a quest of establishing the important psychiatric diagnosis of "substance dependency-induced psychosis" (SDIP). It is likely that half of persons diagnosed as schizophrenic are really cases of SDIP. Three nationally known psychiatric experts have expressed their support for further investigation of the diagnosis. An eastern medical school had been planning to do a clinical trial on the diagnosis. But its priority has recently been downgraded, and it is quite problematic at this as to whether it will ever be organized. Dr. Douglas Ziedonis, the chief of the addictive section of psychiatry at The Robert Wood Johnson Medical School in New Jersey, had been relatively enthusiastic about organizing a clinical trial on the diagnosis. But his enthusiasm dampened not long after he assumed this position from prior position at Yale. I can only guess that the "biologically/politically incorrect? problems of the diagnosis played an important part in this change on his part.

The SDIP illness is similar to schizophrenia. Both are largely functional types of psychoses, and the signs and symptoms are very similar. The SDIP disorder could have been considered as a new subtype of schizophrenia, but that would have diluted the singular importance of the dependency (whether active or not) as the major cause of the psychosis. Additionally, though the concept of schizophrenia is a useful one in psychiatry, that doesn‘t mean it should be considered as a discrete (or sacrosanct) disease entity. One researcher commented about being unable to support the reported finding of a "schizophrenic gene," that it was likely that there were a number of different illnesses included within the diagnosis. The new DSM-IV diagnosis of "substance-induced psychosis" is a largely inadequate diagnosis. It should have been limited to non-addictive substances-though in practice it almost always involves addictive ones.

The SDIP-afflicted person is usually less ill, and likely wouldn’t ever have become psychotic without the "help" of the dependency. The prognosis for the SDIP patient is mainly better because of having better treatment opportunities. This is a specific type of treatment in the form of substance dependency therapy, which is given in the context of the causal role of the dependency for the psychosis. In my experience, one-thirds of fully treated patients enjoy a full remission, without any further need for medication. Antipsychotic medication treatment for the schizophrenic person, though usually effective, is only of a symptomatic type.

I have made no attempt to write a journal article on the substance dependency-induced psychosis diagnosis because of the lack of a clinical trial, the widespread ideological bias against the diagnosis, and finally my role as a "psychiatric outsider." I think trying to do so would have been an exercise in futility without a journal demonstrating some sort of open minded interest on the subject. Recently, I was communicating with a psychiatrist, who had published the only report of a case of the SDIP diagnosis that I have ever encountered. He had waited over a month to respond to my initial e-mail to him. After the exchange of a few e-mails and a long telephone conversation, he suddenly and mysteriously refused to correspond with me any further. He gives lectures all over the country on the problem of dual diagnoses (i.e., psychosis, chiefly diagnosed as schizophrenia and substance dependency). For some reason he had never given the diagnosis any formal name. I never got the opportunity to ask him why he never did so. Perhaps my role as a psychiatric outsider has been an aid to me in accepting the challenge of this diagnosis.

There is a good synopsis of the diagnosis on the web in the form of an interview/article at

http://medicalreporter.health.org/tmr0499/tmro44.htm (be sure to also access my "personal viewpoint"). I also have a web site on the diagnosis at www.athealth.com/Pro/GuestArticles,html or www.athealth.com/ Finally, there is an essay I have written on the subject of "biological psychiatry" at www.mhsource.com/wb/biopsych.htm - which is somewhat of a critical nature.

The science of establishing and using psychiatric diagnoses is inherently more difficult and less precise then in the rest of medicine. And that problem is compounded in the area of substance dependency. "Biological thinking" is currently predominant in the "New Psychiatry" or "Biological Psychiatry." I always put the term "biological" in quotation marks when it is used in this manner. This is because it involves a misuse of the word" biological." Of course, the problem in not with the worthwhile new psychiatric drugs being developed. It is related to their over-valuation. The influence of such thinking has been a marked down-grading of the importance of psychology and psychotherapy in the understanding and treatment of mental disorders. It has actually led to the very unfortunate elimination of any instruction in psychotherapy at many psychiatric training programs. Biological thinking has been the most important source of opposition to the SDIP diagnosis. An enlightening essay about the serious problems of "biological psychiatry" by David Kaiser, MD from the "Psychiatric Times" is featured on my web site.

A university psychiatrist recently cited the statistic that 80% of patients in state hospitals with a diagnosis of schizophrenia have an associated diagnosis of substance dependency. Unfortunately, he accepted the standard "biological premise" that the mental illness comes first. According to this thinking, the addiction obviously couldn’t have been a causal factor for the mental illness. There is a journal report about the finding in an inner city emergency room that 70% of persons with a diagnosis of schizophrenia coming to the emergency room tested positive for cocaine in the urine. Yet the study had the tortured, but "politically/biologically correct" conclusion that the schizophrenia preceded the cocaine addiction. Aside from other common sense problems, such a conclusion runs counter to my consistent finding that the onset of psychosis always decreases the person’s desire for the substance (inversely with the psychosis? intensity).

I received a very interesting report from a substance dependency therapist and counselor at a state hospital mental illness/substance dependency (M.I.S.D.)ward. She reported that, in somewhat over half of such dual diagnosis cases, the addiction clearly came first. However, for "biological psychiatrists" the significance of this finding is largely negated by the convenient "biological understanding" regarding the matter of this sequence. It is that most cases of schizophrenia and substance dependency start incubating about the same time in the late teens. Therefore, the substance use is considered to be merely secondary to the still "subclinical schizophrenic processes" at work. This thinking strikes me as "biologically convenient.:

I very much wish that it would have been sufficient for me to have simply described the merits of the diagnosis to succeed in getting it established. I have decided to get media publicity to aid in the task of organizing a crucially needed clinical trial on the diagnosis. Currently, two newspapers are definitely planning to publish articles on the diagnosis, and two more are seriously considering doing so. I am convinced that this diagnosis is a matter, about which the public really has the right and the need to know. I am also convinced that some medical schools will shortly get interested in investigating the diagnosis in the wake of such publicity. It is a very sure thing that this diagnosis will eventually get established-but I am working hard to see that this is accomplished sooner than much later. This translates to the avoidance of much unnecessary human suffering. I am hoping that this letter will lead directly to some help for persons diagnosed as schizophrenic, who have direct or indirect ties to your organization. I am also hoping that your stated interest in the diagnosis will help in ultimately organizing the much-needed clinical trial on the diagnosis.

I will close with suggestion that the reader access the Medical Reporter interview for information about the diagnosis. There are also a couple of very short clinical case studies there and more on my web page. I would be glad to furnish you with a number of supporting documents, should you request same.

My e-mail address if Norman@mi.verio.com. My telephone number is (810) 293-5489 and mailing address is 31400 Merrily, Roseville, MI 48066 *** written by, Norman Jay Gersabeck, MD