Can Substance Misuse Trigger a Premature Onset of the Prepsychotic Prodromal Stage

In the ABC Schizophrenia Study, the lifetime prevalence of alcohol abuse until age at first admission was 24% for the first-episode sample and 12% for matched controls from the same population [119,136,137], and that of drug abuse 14% for patients and 7% for controls. Studies on the topic almost invariably show a preponderance of men in substance abuse. We found a cumulative prevalence (until first admission) of any type of substance abuse of 39% for men and 22% for women. Cannabis was the most frequently abused substance (88%), followed by alcohol (58%).

In this study, 35% of the patients with drug abuse and 18% of those with alcohol abuse started with the abuse behaviour in the same month as the onset of schizophrenia occurred. In this small group, precipitation of illness onset by substance abuse cannot be excluded, especially since these patients were significantly younger (8 years) at illness onset than non-abusing patients. In contrast, we could not support in our study the dopamine-receptor hypothesis of a drug-related precipitation of the psychotic episode. However, presence of alcohol and drug abuse in the early illness course predicted an elevated score for positive symptoms in both the psychotic episode and at five cross-sections over five years following first admission. In contrast, substance abuse significantly reduced affective flattening with a latency of several years, probably in the context of a dysfunctional self-therapy of apathy. At the same time, substance and drug abuse may have contributed to poorer compliance with antipsychotic therapy, which again could have contributed to an increased level of positive symptoms [137].

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