Schizophrenia and Addiction (and a little TOC)
Long, long ago, when I was a psychiatry resident at Charity Hospital in New Orleans we only had the first generation anti-psychotics to treat schizophrenia. Haldol, Thorazine, and Stelazine were our mainstays. The newer antipsychotic medications were far in the future, but the medicines were still amazing because they were so effective in treating the symptoms of the illness.
To be specific, what we called the symptoms were just the “positive symptoms” of schizophrenia: hallucinations and delusions. There were the negative symptoms too: apathy, lack of emotion, inability to enjoy anything, but these negative symptoms didn’t get much play for two big reasons. First, the medications we had didn’t do much to help them. We had no way to fix them, so we mostly ignored them. The second reason may be why we didn’t have medications in the first place and is even worse. As a society, the negative symptoms didn’t bother us as much as the positive symptoms. No one wants to share a sidewalk with someone having a conversation with a non-existent demon, but no one minds if the guy next to him is quietly miserable.
What’s important to take away from this is that the names we used for these symptom sets: positive and negative. The positive symptoms were outward going; they bothered other people; and they were the focus of socially sanctioned treatment. The negative symptoms on the other hand were inward focused; they bothered no one but the patient and their close family; and they were pretty much ignored by society. The problem with this naming became clear to me as I started studying the older British literature on schizophrenia. They had entirely different way of naming the symptoms.
Instead of calling the symptom sets positive and negative, the British called the same sets primary and secondary. And here’s the surprise. What we were calling negative symptoms were the primary symptoms; they came first. All this time, we were focusing on the effect instead of the cause. We were treating something that came later in reaction to earlier symptoms rather than the earlier symptoms. And why? Because they bothered us.
This all came to mind today because a colleague wrote a post to a professional email group I’m part of. She was asked by her state to remove her patients from buprenorphine (a partial opioid agonist) to cheaper naltrexone (a complete opioid blocker). She asked the group, in response to the state’s request, “why is buprenorphine any better, except of course that it treats the negative symptoms of addiction better.”
I realized all of a sudden we were doing the same thing we’d done so long ago with schizophrenia. Addiction has a positive outward facing set of symptoms (drug use and everything else that goes along with it) that bothers society and an inward facing set of symptoms that don’t (inability to enjoy normally rewarding activities, low motivation, poor sleep, more memory, inability to attend). And again, what my colleague was referring to, as the negative symptoms were primary. They came first. The drug use is a response to the primary symptoms of addiction, not the cause of them.
And again, the answer is in the older literature. This was all known to doctors treating addiction in the late 1800’s, but was forgotten in the moral push against addiction treatment in the early 1900’s. In the 1930’s, one of the last physicians to know this wrote about the base state of the person with addiction being “restless, irritable, and discontented.” He didn’t know that the primary symptom set he was referring to mapped to low midbrain dopamine tone. But we know that now.
Yet here is a state, one of the most affected by an increasing number of deaths from addiction, focused still on the later symptoms that are the effects of the earlier symptoms. Maybe it’s a pattern of American thought, or maybe even a pattern of how the human mind works. Maybe we always think first how to solve the problem in front of us instead of looking for its cause. But if that’s true, it’s also true that we don’t have to resort to that. We realized we were wrong with schizophrenia, and we can realize we are wrong with addiction. If we really want to solve the problem of addiction in America, we can change our model, change our words, and change our minds.