The Cruel Double Whammy: Bipolar and Alcohol or Drug Abuse

Patient Expert

Bipolar may be one of the worst illnesses on the planet, but I would not be writing this and you would not be reading this if we did not believe our condition were manageable to some degree. Throw alcohol or drug use into the mix, however, and all that changes.

I got a major insight into this late last year when I had dinner with a group of NAMI parents. This meant I could expect to hear a lot about schizophrenia, and sure enough in no time I was listening to stories about the heartbreak and frustration these adult kids were putting their parents and the rest of their families through: hospitalizations, homelessness, run-ins with the law, on and on, no let-up.

Then one parent mentioned bipolar, then another, then another.

Bipolar? This didn't sound right.

Then came the other part of the story:  One parent mentioned the alcohol and drugs, then another, then another.

This sounded right. It wasn't "just bipolar" we were talking about. If only. Instead, these parents were dealing with a degree-of-difficulty situation that bordered on just about impossible - a mood disorder combined with substance or alcohol abuse. The condition is interchangeably referred to as dual diagnosis and co-occurring disorder.

How bad is it? Recall that initially I thought these parents were talking about schizophrenia - that's how bad it is.

Six in ten of us with bipolar have experienced a major drug or alcohol problem at some point in our lives. Just about all of us have been in close contact with someone struggling with this cruel double-whammy. I count myself as very lucky that, anxiety and other stuff aside, I "only" have bipolar disorder.

Walk into any DBSA group and you will hear a lot of talk about "self-medicating." The inference is that bipolar is the real condition and that the alcohol and drug use is a maladaptive way of coping with it. Indeed, the math bears this out: if alcoholism or substance abuse were strictly genetic, then why would these genes load so heavily in the bipolar population?

But walk into an AA or NA meeting, and you hear a different story, sometimes from the same people who go to DBSA. Here, you will hear talk about craving, an urgent need to satisfy an unyielding and insatiable and uncontrollable desire.

AA's Big Book makes a very compelling case for the failure of the body to control a craving for a specific chemical - a point of view validated throughout the science and treatment communities. Indeed, researchers are turning up a number of candidate genes for alcoholism and substance use.

The resolution to "self-medicating" vs "craving" appears to be the environment piece of the gene puzzle. Our genes do not necessarily cause certain behavior or predetermine certain behavior. Rather, they appear to "predispose" us to certain behavior if and only if we are exposed to the wrong environmental conditions.

In other words, if you have genes that predispose you to alcoholism but are raised in a family that discourages drinking and have friends who don't drink, then those genes may never get switched on. Marc Schuckitt of UCSD is a leader in the field of how environment affects genes in alcoholism. He has been following a population of at-risk kids into adulthood for more than a quarter century. His latest published article,  Comparison across two generations of prospective models of how the low level of response to alcohol affects alcohol outcomes, helps illustrate the genes-environent two-step.

Likewise, if you have genes that predispose you to bipolar but happen to live out your entire life in a nurturing environment you may never experience a severe depression or mania. The connecting link here is stress. A landmark 2003 study led by Avshalom Caspi of Kings College, Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene, is cited in 521 other publications.

This particular gene is undoubtedly the most-researched gene in the whole field of human behavior. Caspi and his colleagues were very careful to point out that the gene in question was not a "depression gene." Rather, it was more like a "vulnerability to stress gene," and further research is validating this point of view. As well as depression, the gene has been implicated in anxiety, bipolar, personality disorders, a number of other conditions, and - alcoholism.

This gene, needless to say, is hardly the only stress gene, but I think you see where I am going with this: We have "vulnerability genes" that cause us to over-react to stress. This sets us up for all sorts of downstream effects, from depression to anxiety to finding ways to cope with the stress or its downstream effects, including alcohol or drugs.

You probably see where this is going next: The self-medicating turns into a craving. Basically, repeated exposure to alcohol or other drugs change our brains in a way that sets up the need for more. We become prisoners to our neurons. We have fallen into the worst of all possible worlds - the double-whammy of mood meets chemical dependence.

We are no longer "just bipolar." This is a whole new ballgame. Life has just gotten a lot more complicated. And here is the unkindest cut of all: no one treats it. We have people who treat mood disorders, we have people who treat alcohol and drug disorders - same with support groups - but almost never are the two treated together. It's as if when getting a new pair of glasses, we have to go to a separate doctor for each eye. This is crazy, totally crazy.

This is the first in what I am hoping to be an extended series on dual diagnosis/co-occurring. As always, I am looking to you - the real experts - for help on this, but even more so in this case. Because I have not had personal experience with alcohol or substance abuse, I really need to hear from you what it's like and how you manage.

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