BIPOLAR DISORDER AND SEX ADDICTION
Will I become addicted to the medication?
The one major concern for many patients who take psychotropic medications for years is the fear that they will become addicted to or dependent on their medication. Addiction is a complicated and controversial issue that bears some explaining. From a psychopathological or medical standpoint, addiction is defined as the pursuit of a substance in such a manner that the pursuit and use of it consumes so much time and energy for the person that he or she excludes the majority of, if not all, other important activities in his or her life. By that definition, anything that gives pleasure causing pursuit of it with abandon is potentially addictive-from gambling to sex to drugs to even the Internet and all variations on those themes. By that simple definition, no medication for the treatment of bipolar disorder other than the rare possibility of benzodiazepines, which are generally limited in use for that reason, has proven to be addictive.
Many people do, however, become physiologically dependent on various prescription medications, and this is where confusion reigns. Dependency has many definitions, which further confuses the picture. It is seen as a pejorative term, akin to addiction. But one confuses the concept of dependency as defined by the DSM-IV-TR with two other concepts, one being the dependency one has on any medication to treat achronic illness that will flare up if the medication is stopped (e.g., diabetes, heart disease, or epilepsy as well as bipolar disorder); the other being that if one takes a medication chronically, then suddenly stops it and experiences withdrawal symptoms, he or she must be dependent on the medication. Dependency, instead, is more strictly defined in the DSM-IV-TR and is more akin to the previous description of addiction than the misunderstanding of the lay concept. There are two major criteria, the first being an emphasis on ever-increasing use in order to achieve a desired effect, known as tolerance; the second being that the concept of withdrawal includes both physiological and behavioral manifestations and is important in terms of the maintenance of the addictive behavior. This definition is very specific and as a result any physiological withdrawal symptoms that develop from the immediate cessation of a medication do not meet the definitional requirements of substance dependence unless they are accompanied by the other definitional criteria. This causes no end of confusion to both clinicians and the general public.
For example, the most obvious drug that people think about in terms of dependency includes most of the prescription pain medications that are called opiates (heroin is an opiate and was developed because it was thought to be nonaddictive). Everyone who takes these medications on a regular basis will develop some amount of withdrawal symptoms if they stop them abruptly. However, not everyone escalates their use of these medications over time, nor do they engage in reckless behavior in pursuit of the drug as the result of experiencing withdrawal symptoms. Because a druglike an opiate can make one high, is often pursued with abandon, and does cause dependency, people often mistake these two very different notions as one and the same.
Additionally, many medications that do not lead to addiction can cause physiological withdrawal. Many anticonvulsant medications, antihypertensive medications, and all steroid medications cause withdrawal, but no one would ever consider these drugs addictive. In stark contrast, many hallucinogens and stimulants do not cause any measurable physiologic changes in the body that one could absolutely label withdrawal, and nevertheless these are some of the most highly addictive substances known to humans. Where do antimanic agents, antidepressants, and other psychiatric medications fit on this continuum? Some antimanic agents are associated with various withdrawal syndromes, such as the possibility of a withdrawal dyskinesia, a transient movement disorder, associated with the abrupt withdrawal of a typical antipsychotic agent. Most antidepressants cause some level of physiologic dependency, especially the tricyclic antidepressants. Any drug, whether prescription medication or street drug, that causes a withdrawal syndrome must be tapered over time, or one risks developing withdrawal. In fact, three types of discontinuation syndromes can occur when you stop a medication that you have been taking regularly for a significant period of time: withdrawal, rebound, and recurrence. Withdrawal occurs when a drug or medication is abruptly stopped. It is accompanied by clear physiologically measurable changes, including vital sign changes, skin color and temperature changes, and psychological distress. For some drugs, such as benzodiazepines, this can be a life-threatening emergency. For this reason, you must always consult a physician when deciding to discontinue a medication to see whether such a withdrawal could occur. Rebound occurs when the symptoms for which one was receiving the medication become transiently worse than the symptoms one had before treatment. This is a potential risk for any sleep medication from which rebound insomnia can be very severe. However, this is a transient effect and abates within days. Unfortunately, most people do not realize that rebound is expected and transient, and they immediately go back on their sleeping medications.
Rebound generally is not accompanied by any physiologic changes. Recurrence is simply the return of symptoms for which one originally received the medication. Recurrence is more delayed in the timeline after stopping a medication than either withdrawal or rebound. Typically, if you begin to experience symptoms as early as a few days after stopping antidepressant medications, these actually represent rebound or minor withdrawal (no measurable physiologic changes) that is commonly known as a discontinuation syndrome. Rarely is it caused by recurrence. This is why it is a good idea to taper the medications. When the medications are appropriately tapered, any symptoms that return can properly be attributed to recurrence, and thus increasing the medication back to a therapeutic dose may be a wise choice. In summary, clearly, although many psychotropic medications can cause various discontinuation syndromes, they are not addictive. I know that I am not physically addicted to my medication, although I also know that if I were to go off of any of it I would have to do it slowly so that my brain chemistry could adjust to the changes. I do, however, know that I am dependent on the medication and it is frightening to think what might happen and how I would end up feeling if I didn’t take it for a prolonged period of time. That fear makes me dependent but I also believe that being on the medication is like treating any other biologically-based illness: It is necessary to remain healthy.
Terms:
Addiction – continued use of a mood-altering substance despite physical, psychological, or social harm. It is characterized by lack of control in the amount and frequency of use, cravings, continued use in the presence of adverse effects, denial of negative consequences, and tendency to abuse other mood-altering substances.
Dependence – the body’s reliance on a drug to function normally. Physical dependence results in withdrawal when the drug is stopped suddenly. Dependence should be contrasted with addiction.
Dyskinesia – an impairment in the ability to control movements
