"Everybody gets a little bit loco”: Interactions between psychotic experiences and substance use as dimensional phenomena

Abstract: A large amount of persons with psychosis experience problems related to substance use; and many persons with substance use disorders develop psychiatric symptoms, including psychotic experiences (PEs). The co-existence of PEs and substance use disorders increases the risk for social exclusion, health adversities, violence, and aggravation of symptoms. Besides social exclusion, one of the main factors behind this association is a need for alleviation of distress, or compensatory affect regulation in relative absence of other strategies or protective factors. This may drive a feedback loop between anxiety, increased substance use, lowered self-efficacy, and PEs. There is a need for more research that contributes to the understanding of interactions between substance use, affect regulation and psychopathological processes, not the least since this may have implications for development of psychological treatment. The aim of Study 1 was to examine aspects of substance use patterns in a group of persons with psychosis (n=16), in comparison with a group of persons with other mental health problems (n=22). The results indicate lesser mental state references to substance use and lesser signs of alcohol dependence in the group of persons with psychosis, but no significant differences in overall consumption. The aim of Study 2 was to explore the interactions of substance use and affect regulation within the group of persons with psychosis. Interviews were conducted with twelve participants, and the transcripts were analyzed according to thematic analysis. The material was structured along the lines of two main themes; Approaches to distress and Regulating functions of substances. The results suggest a general tendency to use substances to regulate affect and self-experience in the same time as displaying a great heterogeneity within the group concerning substance use patterns, regulating functions and self-reflection. A possible interpretation is that level of self-reflection and affect regulation style influence pattern and function of substance use on a more primary level than type of psychiatric illness, but that more elaborated levels of self-reflection often are problematic for persons with psychosis. The aim of Study 3 was to investigate the prevalence of PEs in a group of socially stable persons with alcohol use disorders, and possible differences in childhood trauma and alcohol-related self-efficacy between persons in this group with low and high levels of PEs, respectively. The results suggest that a large minority of this group display substantially elevated levels of PEs, and that this is strongly correlated to childhood trauma and perceived difficulties in abstaining from alcohol. One hypothesis generated by the studies, is that capacities of affect consciousness in combination with difficulties in higher order self-reflection, are associated with the highest risk for developing a substance use disorder in persons with psychosis, since it may lead to emotional pain that calls for quick discharge. The integrated result suggests that there is an association between anxiety (often trauma-related), substance use and PEs irrespective of which problem is considered “primary”, and that substance use and PEs should be seen as dimensional and interacting phenomena rather than separate “disorders”.