Is It Schizophrenia? Is It Substance Use?

Around ten million adults in the United States currently experience both mental illness and a substance use disorder (SUD). It’s a well-established correlation, often complicating the treatment of both conditions. One such co-occurring disorder is schizophrenia

In a recent webinar for Harmony Foundation, Colorado Recovery’s medical director Alan Fine, M.D., talked about the symptoms of schizophrenia and substance use disorder and why it is frequently difficult to tell the two conditions apart.



First off, Dr. Fine presented a diagnostic flowchart to illustrate where SUD and schizophrenia can be found in the mental healthcare realm. If the symptoms are acute and were caused by taking drugs or drinking alcohol then we’re looking at substance misuse and a possible addiction scenario. If the diagnosis is psychosis without a physical cause, the condition is often diagnosed as schizophrenia or bipolar disorder. 

The diagnosis of schizophrenia itself is complicated and based on the work of three trailblazers in the field whose impact can still be felt today: Emil Kraepelin (1856–1926), Eugen Bleuler (1857–1939), and Kurt Schneider (1887–1967). 

Kraepelin is considered one of the founders of modern scientific psychiatry. His views dominated the field at the start of the 20th century. Bleuler renamed Kraepelin’s “dementia praecox” schizophrenia and established the classic four As of the condition: ambivalence, affect, alogia, and autism (preoccupation with self). Schneider in turn formulated the first-rank symptoms of schizophrenia: auditory hallucinations, feelings of external control, thoughts connected to others, and other delusions.  

In his book, The Environment of Schizophrenia, Colorado Recovery founder Richard Warner wrote that “schizophrenia is a psychosis. That is to say, it is a severe mental disorder in which the person’s emotions, thinking, judgment, and grasp of reality are so disturbed that his or her functioning is seriously impaired.”

What about substance use then?

By definition, schizophrenia is not caused by the effects of a substance or another medical condition. That, however, is not quite all. 

Mental health conditions and SUDs frequently co-occur because many people with addiction are primarily misusing addictive substances to self-medicate emotional pain caused by serious mental health disorders. 

“The proportion of schizophrenic patients of comorbidity of substance abuse varies in published studies from 10–70 percent, depending on how patients are diagnosed with schizophrenia, the types of populations studied, and the different ways of defining drug and alcohol disorders,” said Dr. Fine. “There’s a remarkable overlap in both directions.”

People with schizophrenia are at a higher risk of engaging in substance misuse because many of them will be tempted to self-medicate the severe symptoms of their mental illness as well as some of the side effects of their antipsychotic medications. At the same time, substance misuse may cause syndromes that are similar or even identical to schizophrenia.

In the short term (acute intoxication), schizophrenia-like symptoms may include delusions (stimulants and inhalants), loose associations (stimulants, alcohol, sedatives, and inhalants), and hallucinations (stimulants, alcohol, and inhalants). Both alcohol and sedative withdrawal symptoms include hallucinations and paranoia. 

In the long term (prolonged misuse), “amphetamine use is associated with long-term psychosis—thirty percent of all amphetamine-induced psychoses become chronic,” Dr. Fine explained. Chronic alcohol misuse may cause persistent dementias such as Korsakoff syndrome and delirium tremens. 

People with schizophrenia also engage in substance misuse to cope with the deterioration of their social environment, an area that Dr. Warner explored extensively

So, the answer to the question “Is It schizophrenia or is it substance misuse?” is often: both! That means, should both conditions be present, both need to be treated because they may reinforce each other. An important element in this regard is empowerment

Empowering people with schizophrenia reduces the need to self-medicate and often improves symptoms. Believing in their ability to take charge of their lives and manage the complex challenges of their illness is crucial for people with schizophrenia.

Over the course of his long professional career, the late Dr. Warner realized that social inclusion empowers people with mental illnesses and improves outcomes. “Work helps people recover from schizophrenia,” Warner concluded. “Productive activity is basic to a person’s sense of identity and worth.”

Colorado Recovery has been utilizing the Warner method to empower adults with mental illness for many years now. Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.


What’s the Typical Age of Onset for Schizophrenia?

Schizophrenia is a mental health condition that affects about one percent of the US population. That means approximately 3.3 million people nationwide currently live with the condition. It typically starts in late adolescence or early adulthood.

“Schizophrenia is a psychosis,” explained Colorado Recovery founder Richard Warner, MD, in his book The Environment of Schizophrenia (2000). “That is to say, it is a severe mental disorder in which the person’s emotions, thinking, judgment, and grasp of reality are so disturbed that his or her functioning is seriously impaired.”

Schizophrenia can have very different symptoms in different people. They are frequently categorized as positive or negative. “Positive symptoms are abnormal experiences and perceptions like delusions, hallucinations, illogical and disorganized thinking, and inappropriate behavior,” wrote Dr. Warner in The Environment of Schizophrenia. “Negative symptoms are the absence of normal thoughts, emotions, and behavior; such as blunted emotions, loss of drive, poverty of thought, and social withdrawal.”

The onset of schizophrenia usually occurs between the ages of 16 and 30.

“Onset of schizophrenia before the age of 14 is rare, but when it does begin this early it is associated with a severe course of illness. Onset after the age of 40 is also rare, and is associated with a milder course,” wrote Dr. Warner.

Schizophrenia researchers have long been puzzled about why the illness normally begins in adolescence when important risk factors, such as genetic loading and neonatal brain damage, are present from birth or sooner. Some experts suspect that the natural and adaptive process of synaptic elimination in the brain during childhood—if excessive—could be a factor in the development of schizophrenia.  

“We now know that, for people with schizophrenia, this normally useful process of synaptic pruning has been carried too far, leaving fewer synapses in the frontal lobes and medial temporal cortex,” Warner wrote. “In consequence, there are deficits in the interaction between these two areas of the brain in schizophrenia which reduce the adequacy of working memory.”

There is wide variation in the course of schizophrenia as well. 

“In some cases the onset of illness is gradual, extending over the course of months or years; in others, it can begin suddenly, within hours or days. Some people have episodes of illness lasting weeks or months with full remission of symptoms between each episode; others have a fluctuating course in which symptoms are continuous; others again have very little variation in their symptoms of illness over the course of years. The final outcome from the illness in late life can be complete recovery, a mild level of disturbance, or continued severe illness.”

Left untreated, schizophrenia may result in severe problems affecting every area of life. Complications associated with schizophrenia include:

  • Suicide attempts and thoughts of suicide
  • Anxiety disorders and obsessive-compulsive disorder 
  • Depression
  • Misuse of alcohol or other substances
  • Financial problems and homelessness
  • Social isolation
  • Health and medical problems

Doctors cannot cure schizophrenia, but it is possible to live well if you have this mental illness. “People with schizophrenia can be treated effectively in a variety of settings,” wrote Dr. Warner. 

The treatment philosophy at Colorado Recovery includes a warmer and more human familial setting; comprehensive levels of care that result in a path of self-reliance; expert staff to better diagnose and treat clients; and community engagement for connection and a feeling of achievement. 

Since Dr. Warner’s passing in 2015, Colorado Recovery has continued to innovate its treatment approach based on these core principles. The Warner model has delivered exceptional outcomes through its signature continuum of care and helped create lives of purpose as clients practice new tools in the management of their mental health disorder.

Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses which are specific to each individual. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.