Substance Related & Addictive

Disorder
• The most commonly abused drugs have been part of human existence for

thousands of years.

• Eg: opium has been used for medicinal purposes

• Cannabis as a medicinal in ancient Chinese herbals

• Natives of western hemisphere smoked tobacco and chewed coco leaves

• As new drug were discovered, new routes of administration developed, new

problems related to their use emerged.

• Substance use disorders are complicated psychiatric conditions and like

other psychiatric disorders, both biological factors and environmental

circumstance are etiologically significant.

 How Are Drugs Taken?

• Drink (Alcohol)
• Eat (swallow pills, dissolve on tongue)
• Inhale
• Snort (sniff powder through nostrils)
• Sniff vapors (heroin from opium plant – “chasing the dragon”)
• Inject
• Intravenous – into a vein
• Intramuscular –into a muscle
• Subcutaneous – “skin popping”
 Introduction

• DSM-V, changed the name from alcohol and drug dependence to

substance related now to substance related and addictive disorders.

Addiction

• The repeated and increased use of a substance, the deprivation of

which gives rise to symptoms of distress an irresistible urge to use the

agent again and which leads also to physical and metal deterioration.
• Dependence – (a) Physical

(b) Psychological
 Physical Dependence
Psychological Dependence

An altered physiological state caused by

A person’s resources for coping with
repeated administration of a drug, the
daily life, where a drug becomes
cessation of which results in a specific
“needed” to relax, socialize or sleep.
syndrome.
 Substance Related Disorder

• Encompass 10 separate classes of drugs – alcohol, caffeine, cannabis,

hallucinogens (LSD), inhalants, opioids, sedative(cocaine), hypnotics,

tobacco & other substance.

• All drugs that are taken in excess have in common direct activation of the

brain reward system, which is involved in the reinforcement of behaviours

and the production of memories.

• They produce such an intense activation of the reward system that normal

activities may be neglected.

• Instead of achieving reward system activation through adaptive behaviours,

drugs of abuse directly activate the reward pathways.

• The pharmacological mechanisms by which each class of drugs produces

reward are different, but the drug typically activate the system and produce

feeling of pleasure, often referred to as a “high”.

• Gambling disorder is included in this category, because gambling

behaviours activate reward system similar to those activated by drugs of

abuse and produce some behavioural symptoms that appear comparable to

those produced by the substance use disorders.

• Repetitive behaviour –exercise addiction, shopping addiction are not

included because now there is insufficient peer-reviewed evidence to

establish the diagnostic criteria & course description needed to identify

these behaviours as mental disorders.

 Substance-Related Disorder
Substance Use Disorder:

• Substance Dependence + Substance Abuse

Substance Induced Disorder

• Substance intoxication

• Substance Withdrawal

• Substance induced mental disorder

 Substance Use Disorders

• Essential feature – a cluster of cognitive, behavioural & physiological

symptoms indicating that the individual continues using the substance

despite significant substance-related problem.

• Except caffeine, applicable to all other class of substance.

• An important characteristics – an underlying change in brain circuits that

may persist beyond detoxification, particularly in individuals with severe

disorders.

• This can be exhibited in form of repeated relapse and intense craving when

individuals are exposed to drug related stimuli.

 Alcohol Use Disorder

• AUD is defined by a cluster of behavioural and physical symptoms, which

can include withdrawal, tolerance and craving.

• Alcohol withdrawal is characterized by withdrawal symptoms that develop

approximately 4-12 hours after the reduction of intake following prolonged,

heavy alcohol ingestion.

• Because withdrawal from alcohol can be unpleasant and intense, individuals

may continue to consume alcohol despite adverse consequences, often to

avoid or to relieve withdrawal symptoms.

• Some withdrawal symptoms(sleep problems) can persist at lower intensities

for months & can contribute to relapse.

• Once a pattern of repetitive and intense use develops, individuals with

alcohol use disorder may devote substantial periods of time to obtaining &

consuming alcoholic beverages.

• Craving for alcohol is indicated by a strong desire to drink that makes it

difficult to think of anything else and that often results in the onset of

drinking.
• School and job performance may also suffer either from the aftereffects of

drinking or from actual intoxication at school or on the job, child care or

household responsibilities may be neglected and alcohol related absences

may occur from school to work.

• The individual may use alcohol in physically hazardous circumstances (rash

driving).

• Finally, individuals with an alcohol use disorder may continue to consume

alcohol despite the knowledge that continued consumption poses significant

physical (liver disease), psychological (depression), social or interpersonal

problems (violent argument with spouse while intoxicated, child abuse).

 DSM5- Criteria SUD
• A problematic pattern of alcohol use, leading to clinically significant

impairment manifest by at least 2 symptoms, occurring within

12months:
• Alcohol is often taken in larger amounts or over a longer period than was

intended.

• There is a persistent desire or unsuccessful efforts to cut down or control

alcohol use.

• A great deal of time is spent in activities necessary to obtain alcohol, use

alcohol or recover from its effects.

• Craving or a strong desire or urge to use alcohol.

• Recurrent alcohol use resulting in a failure to fulfil major role obligation at

work, school or home.

• Continued alcohol use despite having persistent or recurrent social or

interpersonal problems caused or exacerbated by the effects of alcohol.

• Important social, occupational or recreational activities are given up or

reduced because of alcohol use.

• Recurrent alcohol use in situations in which it is physically hazardous.

• Alcohol use is continued despite knowledge of having a persistent or

recurrent physical or psychological problems that is likely to have been

caused or exacerbated by alcohol.

• Tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to

achieve intoxication or desired effect

(b) markedly diminished effect with continued use of the same

amount of the substance.

• Withdrawal, as manifested by either of the following:

(A) the characteristic withdrawal syndrome for the substance

(b) the same (or a closely related) substance is taken to relieve or

avoid withdrawal symptoms.

Specifiers
• In early remission – criteria for AUD were previously met, and none of the

criteria for AUD criteria have been met for atleast 3 months but for less than

12 months (craving may present).

• In sustained remission- criteria for SUD were previously met, none of

criteria for AUD have been met at any time during a period of 12months or

longer (craving).
• In a controlled environment- used if the individual is in an environment

where access to alcohol is restricted. (Further specifier of remission).

• Specify current severity:

a) Mild – presence of 2-3 symptoms

b) Moderate – presence of 4-5 symptoms

c) Severe – presence of 6 or more symptoms.

Associated Diagnosis
• Repeated intake of high doses of alcohol can affect nearly every organ

system.

• Gastrointestinal – gastritis, stomach ulcer, & liver cirrhosis, high rate of

cancer of the esophagus, stomach.

• Regular intake of alcohol- increased low-density lipoprotein

cholesterol(LDL)- risk for heart disease.

• Cognitive deficits, severe memory impairment & degenerative changes in

cerebellum.

• Wernicke-Korsakoff syndrome- ability to encode new memory is severely

impaired – neurocognitive disorders- substance/medication induced

neurocognitive disorder.
Is addiction an illness or a habit?
Abuse and Misuse

• Abuse- Use of any drug, usually by self-administration, in a manner that

deviates from approved social or medical patterns.

• Misuse- similar to abuse, but usually applies to drugs prescribed by

physicians that are not used properly.

 Substance induced Disorders

• Intoxication

• Withdrawal

• Substance/medication induced mental disorders

Alcohol Intoxication

• Essential feature – presence of clinically significant problematic

behavioural or psychological changes (inappropriate sexual or aggressive

behaviour, impaired judgment & social & occupational functioning) that

develop during or shortly after, alcohol ingestion.

• 1 or more of following symptoms developing during or shortly after alcohol
use:
Slurred Speech
Incoordination
Unsteady Gait
Impairment In Attention And Memory
Stupor Or Coma
Nystagmus (rapid involuntary movement of eyes)
• These changes are accompanied by evidence, of impaired functioning and

judgment & if intoxication is intense, can result in a life-threatening coma.

• The symptoms must not be attributable to another medical condition.

 Substance Withdrawal

• The essential feature is the development of a substance specific

maladaptive behavioural change, with physiological and cognitive

symptoms, that is due to the cessation of, or reduction in, heavy and

prolonged substance use.

• 1 or more of following symptoms:
Autonomic hyperactivity
Increased Hand tremor
Insomnia
Nausea or vomiting
Hallucination
Anxiety
Generalized tonic-clonic seizure
• The symptoms cause clinically significant distress or impairment in social,

occupational or other major areas of functioning.

 Substance Induced Mental Disorder

• The disorder represents a clinically significant symptomatic

presentation of a relevant mental disorder.

• The disorder develop during or within 1 month of a substance

intoxication or withdrawal.
• The involved substance/ medication is capable of producing the

mental disorder.

• The disorder is not better explained by an independent mental

disorder.

• The disorder cause significant impairment in major area of

functioning.
Etiology
 Psychological Factors

 Impulsivity – Inability to effectively control or restrain behavior.

 Negative Affect – Dysphoric moods such as anxiety & depression.

 Poor Coping – Deficits in cognitive and behavioral skills or inhibitions

in the ability to perform behaviors due to the effects of anxiety.

 Sociocultural Factors

• Family History – Dysfunctional family settings especially parental

alcohol and drug problems and parental abuse or neglect of children.

• Peer Influences – Social pressure to engage in risk-taking behaviors

including substance use especially when related to gang membership.

 Sociocultural Factors

• Culture and Ethnic Background – Norms and religious beliefs that

govern the use of alcohol and drugs and ethnic variations the body’s

rate and efficiency of metabolizing drugs and alcohol.

• Media/Advertising – Societal emphasis on immediate gratification and

glorification of the effects of alcohol and drug use.

 Psychodynamic Factor
• Substance abuse is a masturbatory equivalent (heroin users describe the initial

use as similar to a prolonged sexual orgasm), a defence against anxious

impulses, or a manifestation of oral regression (i.e., dependency).

• Recent psychodynamic formulations relate substance use as a reflection of

disturbed ego functions (i.e., the inability to deal with reality).

 Psychodynamic Factor
• As a form of self-medication, alcohol may be used to control panic,

opioids to diminish anger, and amphetamines to handle depression.

• Some addicts have great difficulty recognizing their inner emotional

states, a condition called alexithymia (i.e., being unable to find words to

describe their feelings).

Learning and Conditioning

• Drug use, whether occasional or compulsive, can be viewed as behaviour

maintained by its consequence.

• Drugs can terminate some aversive state like pain, anxiety or depression.

• In some social situation, drug use can be reinforcing if it results in special

status or the approval of friends.

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.

• Researchers recently have used restricted fragment length polymorphism

(RFLP) in the study of substance abuse and dependence & associations to
genes that affect dopamine production have been postulated.
Pathways and Neurotransmitters

• Major neurotransmitter involved in substance abuse & dependence is –

catecholamine, GABA.

• The dopaminergic neurons in the ventral tegmental area (part of mid

brain)are particularly important.

• The neuron project to cortical & limbic system which in involved in

sensation of reward.
 Treatment Plan
(A) MET – Individual therapy

(B) RPT – Individual therapy

(C) Family therapy

(D) Group therapy -AA

(E) Pharmacotherapy –Aversion therapy- Disulfiram

 Stages of Change in Substance Abuse &
Dependence: Intervention Strategies

Maintenance
Stage

Precontemplation Contemplation Preparation Action

Stage Stage Stage Stage

Relapse
Stage
Motivational
Enhancement Assessment
Strategies & Treatment Relapse
Matching Prevention
& Relapse
Management
 Decision Matrix
ALCOHOL ABSTINENCE ALCOHOL USE

POSITIVE NEGATIVE POSITIVE NEGATIVE

Immediate Consequences Immediate Consequences

Improved Immediate
Frustration; Feeling that
self-efficacy, reduction of
denial of one has
confidence anxiety; revenge
pleasure; lost control;
and esteem; against one’s
anger at anger at family
family approval; spouse; better
oneself for and employer;
better health; feeling about work;
not doing financial loss;
financial gains; immediate
what one wants weakness
continued success gratification
Delayed Consequences Delayed Consequences
Continued
Enhanced ability Feeling as though
deterioration;
to control Denial of one is
loss of one’s
one’s life; immediate caught in a
family; loss of
more money; and seemingly fog, so one
one’s employment;
more respect; easy doesn’t have
poor health;
greater gratification to deal with
loss of friends;
popularity reality
greater self-hatred
 A Cognitive Behavioral Model of
the Relapse Process
Effective coping Increased Decreased
response self-efficacy probability of
relapse

High-Risk
Situation

Ineffective Lapse Increased

coping response (initial use of the probability of
substance)
relapse

Decreased Abstinence
Self-efficacy Violation Effect
¤ ¤
Positive outcome
Expectancies Perceived effects
(for initial effects of of the substance
the substance)
 Relapse Prevention: Specific Intervention Strategies
Self-Monitoring
¤ Mediation, Contract to limit
Inventory of Relaxation Training, extent of use
Drug-Taking Situations Stress Management ¤
¤ ¤ Reminder Card
Drug Taking Efficacy-Enhancing (what to do if
Confidence Imagery you have slip)
Questionnaire

Decreased
Ineffective Self-Efficacy
High-Risk ¤ Abstinence
Situation Coping Lapse Violation Effect
Positive
Response
Outcome
Expectancies

Description of Cognitive
Past Relapses Restructuring
¤ Situational (a lapse is a mistake:
Relapse Fantasies Education about coping vs.
Competency Test immediate vs.
¤ delayed effects
Coping-Skill ¤
Training Decision Matrix
¤