1. Substance-Related Disorders

2. Overview Survey around 1997: 37% of population reported using one or more illicit substances in their lifetime; 13% used within the past year 6% used in the month prior to the survey. 18 - 25 age group: more than 67% had used More than 15% of the U.S. population over 18 have serious substance use problem 67% of this group use alcohol remainder use other substances Cost to society in late 1990s - almost $200 Billion annually

3. Overview (cont’d) DSM-IV concept of psychoactive substance does not include chemicals with brain-altering properties such as organic solvents (ingested on purpose or by accident). Legal substances cannot be separated from illegal substances. For example, morphine (legal) can be obtained thru illegal means. The word substance is used in place of drug, because drug implies a manufacturedd chemical, whereas many substances associated with abuse pattern occur naturally (opium) or are not meant for human use (airplane glue). DSM-IV approaches substances as associated with a pathological intoxication state, but varies on whether a pathological state is associated with withdrawal or persists after the elimination of the substance from the body.

4. DSM-IV Substance-Induced Disorders Outside of Substance-Related Disorders Category Substance intoxication delirium Delirium, dementia, and amnestic and other cognitive disorders Substance withdrawal delirium “ “ “ “ “ “ Substance-induced persisting dementia “ “ “ “ “ “ Substance-induced persisting amnestic d/o “ “ “ “ “ “ Substance-induced psychotic disorder Schizophrenia and other psychotic disorders Substance-induced mood disorder Mood disorders Substance-induced anxiety disorder Anxiety disorders Substance-induced sexual dysfunction Sexual and gender identity disorders Substance-induced sleep disorder Sleep disorders

5. Substance Dependence WHO recommended changing from using “addiction” to dependence in 1964, claiming that “addiction” was no longer a scientific term. Two concepts of dependence: behavioral and physical. Behavioral: substance seeking activities and related evidence of pathological use patterns are emphasized. Physical: refers to the physiological effects of multiple uses. The term “addict” has come to mean something unseemly and ignores the concept that substance abuse is a medical disorder. Despite its lack of use in professional circles, it appears that addiction, whether alcohol, drugs, gambling, sex, stealing, or eating, may have common neurochemicals and neuroanatomical substrates.

6. Substance Abuse DSM-IV defines substance abuse as characterized by the presence of at least one specific symptom indicating that substance use has interfered with the person’s life. People cannot meet the criteria for substance abuse if they have ever met the criteria for dependence on the same substance. Since a high of over 25 million users of illicit drugs in 1980, use has been dramatically reduced to current levels of about 11-12 million.

7. General Information 35 - 65 percent of patients with substance abuse or dependence also meet the criteria for a diagnosis of Antisocial Personality Disorder. Depressive symptoms are also common among opioid users, with about 50 percent presenting with depressive symptoms. About 40 percent of alcohol abusers also present with depressive symptoms. People who abuse substances are 20 times more likely to die by suicide than the general population. About 15 percent of alcohol abusers have been reported to have committed suicide (second only to patients with major depressive disorder).

8. Psychodynamic Factors in Substance Abuse Formerly viewed as a masturbatory equivalent, a defense against homosexual impulses, or a manifestation of oral regression. More recently viewed as a reflection of disburbed ego function. Psychodynamic approaches to treatment are more favorable for substances other than alcohol. Polysubstance abusers are more likely to have had unstable childhoods, to self-medicate, and more likely to benefit from psychotherapy. Much research links personality disorders to the development of substance dependence.

9. Coaddiction Also called codependence - has been rejected by experts as invalid in recent years. Concept is that people have a relationship that is responsible for maintaining addictive behavior in at least one partner. Each person may exhibit enabling behaviors that help perpetuate the situation and denial of the situation is a prerequisite for such a dyadic relationship to develop.

10. Behavioral Theories Some models have focused on the substance-seeking behavior rather than on symptoms. Four major behavioral principles at work: Positive reinforcing qualities Adverse effects of some substances Discriminate the substance of abuse Cues

11. Genetic Factors Strong evidence from studies of twins, adoptees, and siblings brought up separately indicates that the cause of alcohol abuse has a genetic component. Other substances do not show such a strong correlation

12. Neurochemical Factors Researchers have identified neurotransmitters or receptors on which substances have their effects. For example, opiates act on opiate receptors. A person with low concentration of endorphins or too much opiate antagonist may be at risk for developing opioid dependence. Even in the absence of the above, chronic use can modulate the receptors to need the chemical to maintain homeostasis.

13. Other Substance-Related Disorders Anabolic steroids. Initially produce a sense of well being. Later produce depressive symptoms, irritability, and liver disease. Nitrite inhalants. Produce an intoxication with “fullness” feeling in the head, mild euphoria, a change in perception of time, relaxation of smooth muscles, and a possible increase in sexual feelings. Deprive the brain of oxygen, cause a toxic reaction including vomiting, severe headache, hypotension, and dizziness. Nitrous oxide. “Laughing gas.” Rapid intoxication with lightheadedness and floating sensation. Chronic use can cause confusion and reversible paranoid states.

14. Other Substance-Related Disorders Catnip. Produces a state similar to marijuana and in high doses causes LSD like reactions. Betel nut. Causes mild euphoria and floating sensation. Kava. Produces sedation, incoordination, weight loss, mild forms of hepatitis, and lung abnormalities. Over the Counter Medications and Prescription Drugs like cortisol, antiparkinsonian agents, and antihistamines that have anticholinergic properties can create a dependence and cause serious medical problems.

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