Chapter 11 - Substance Related and Addictive Disorders

What is DSM-5-TR Substance Use Disorder

• Maladaptive pattern of behaviors that are related to the continued use of drugs despite creating problems for the person, such as:

  • Inability to control use of drug

  • Risky use of drug

  • Social impairment following repeated use

  • Physiological consequences

What categories were used in the DSM-IV-TR that are no longer used?

Substance Abuse and Substance Dependence

What is the DSM-5-TR criteria for Substance Use Disorder?

• Problematic pattern of use that impairs functioning

  • Two or more symptoms within a 1-year period

    • Failure to meet obligations

    • Repeated use in situations where it is physically dangerous

    • Repeated relationship problems

    • Continued use despite problems caused by the substance

    • Tolerance

    • Withdrawal

    • Efforts to reduce or control use do not work

    • Much time spent trying to obtain the substance

    • Social, hobbies, or work activities given up or reduced

    • Craving to use is strong

How is substance use disorder characterized?

By the specific substance

What are the specific substances that can be used for categorization?

• Alcohol

• Cocaine

• Opioid

• Sedative/hypnotic/anxiolytic

• Gambling (new to DSM-5)

• Amphetamine

• Hallucinogen

• Phencyclidine

• Tobacco

• Cannabis

• Inhalant

What is poly substance abuse?

People with substance abuse disorders frequently abuse more than one drug; comorbid diagnoses

What are the physiciolgical features of substance use disorder?

• Tolerance

• Withdrawal

What is tolerance?

• Process through which the nervous system becomes less sensitive to the effects of alcohol or any other drug of abuse

• Substance taken for a longer time or in greater amounts than intended

What is withdrawal?

symptoms experienced when a person stops using a drug

What are more features associated with?

Problematic use of chemical substances

• Craving

• Psychological dependence

• Diminished control

What is craving?

forced urge to use drugs

What is diminished control?

• describes the increasing dependence associated with abuse

  • When a person has less “freedom of choice” about using the drug

What are psychoactive substances?

chemicals that alter a person’s mood, level of perception, or brain functioning

What do depressants include?

alcohol and hypnotics

what are sedative or anxiolytics used for?

to receive anxiety

what drugs are stimulants?

amphetamine, cocaine, nicotine, caffeine

What are narcotic analgesics?

clinical pain reducers

what do cannabinoids do?

produce euphoria and an altered sense of time

What organs in the body does alcohol affect?

virtually every organ

What is the rate at which alcohol is absorbed at influenced by?

• Concentration of alcohol in the beverage

• Volume and rate of consumption

• Presence of food in the digestive system

What are the short-term effects of alcohol use disorder?

• BAC - amount of alcohol per unit of blood

• Slurred speech, lack of coordination, unsteady gait, impaired attention or memory and stupor or coma

• Blackouts

What are the long-term effects of alcohol use disorder?

• Disruption of relationships with family and friends

• Interfere with job performance

• Problems with legal authorities

• Disrupt functions of organ systems - pancreas, endocrine glands, cirrhosis of liver

• Nutritional disturbance - malnutrition

• Heart failure, hypertension, stroke

• Injury and premature death

• Increased risk of fetal alcohol syndrome (FAS)

What is nicotine?

addicting agent of tobacco which stimulates dopamine neurons in mesolimbic area and it is involved in reinforcing effect

What is the most preventable cause of premature death in the U.S.?

Smoking

What is the most common cancer?

Lung cancer - 87% caused by smoking

What do cigarettes also cause or exacerbate?

• Emphysema; cancers of larynx, esophagus, pancreas, bladder, cervix and stomach; cardiovascular disease

• Sudden infant death syndrome (SIDS) and pregnancy complications

What are the short-term effects of tobacco use disorder?

• On the peripheral nervous system includes increasing heart rate and blood pressure

• In the central nervous system, effects neurotransmitter systems such as norepinephrine, dopamine, serotonin

• Complex influence or subjective mood states

What is the paradoxical phenomenon?

users report feeling more relaxed but nicotine increases arousal of sympathetic nervous system

What are the long terms consequences of nicotine?

• Nicotine is one of the most harmful and deadly drugs

• Attempting to quit smoking typically experience sleeping problems, weight gain, concentration difficulties and mood swings

What do amphetamines and cocaine do?

Increase alertness and motor activity; reduce fatigue

What are amphetamines?

synthetic stimulants

• ex. benzedrine, dexedrine, methedrine

What is methamphetamine (crystal meth)?

amphetamine derivative

• can be taken orally, iv or intranasally

What is cocaine?

Obtained from coca leaves

• Crack - cocaine in rock crystal form

What are the short-term effects of amphetamines and cocaine?

• Stimulants - activate the sympathetic nervous system

• Increase heart rate and blood pressure

• High levels of energy, sleeplessness

• Constrict blood vessels in skin and air passages of the lungs

• Suppress appetite and prevent sleep

• Overdoses

What are overdoses?

irregular heartbeat, convulsions, coma, and death

What are the long-term effects of amphetamines and cocaine?

• High does can lead to the onset of psychosis

• Tolerance quick to develop

• Disruption of occupation and social roles

• Prolonged use leads to sexual dysfunction

• Prolonged linked to an increase in violent behavior

  • Unclear whether due to the drug itself or to lifestyles it is frequently associated

What is opiate use disorder?

• group of addictive sedatives that in moderate doses relieve pain and induce sleep

  • Produce euphoria, drowsiness, and lack of coordination

  • Loss of inhibition, increased self-confidence

  • Severe letdown after about 4 to 6 hours

What are some common examples of opiate use disorder?

• opium, morphine, heroin, codeine

• Legally prescribed pain medications including:

  • Hydrocodone or Oxycodone

  • Vicodin, Zydone, Lortab, OxyContin, Percodan, Percocet, and Fentanyl

What are the short-term effects of opiate use disorder?

• Dreamlike euphoria, with increased sensitivity in hearing and vision

• Positive emotional effects of opiates do not last

• Can induce nausea and vomiting among novice users

• Constrict the pupils of the eye

• Disrupt the functioning the digestive system

What are the long-term effects of opiate use disorder?

• At high doses, chronically lethargic and lose motivation to remain productive

• Tolerance develops rather quickly - risks for overdose

• Severe health consequences are often result of lifestyle rather than drug itself

  • Increased risk for homicide, suicide and accident

  • Illegal activities to obtain drug or money for drug

  • Exposure to infectious diseases via shared needles

What are sedatives, hypnotics and anxiolytics also known as?

Barbiturates and benzodiazepines

What are common examples of sedatives, hypnotics, and anxiolytics?

Xanax, Amytal, Nembutal, Valium, Ativan

What are the short term effects of sedatives, hypnotics and anxiolytics?

• Intoxication that is identical to that associated with alcohol

• Impaired judgement, slowness of speech, lack of coordination, a narrowed range of attention, and a disinhibition of sexual and aggressive impulses

What are the long term effects of sedatives, hypnotics and anxiolytics

• Discontinuance syndrome

• Withdrawal can include irritability, paranoia, sleep disturbance, agitation. muscle tension, restlessness, and perceptual disturbances

what is discontinuance syndrome?

may experience if abruptly stop taking high doses; possible worsening of the original anxiety symptoms

What is cannabis use disorder?

• Marijuana and hashish are derived from the hemp plant, Cannabis sativa

  • Major active ingredient: THC (delta-9-tatrahydrocannabinol)

  • Most frequently used illicit drug U.S.

  • Greater use by men than women

  • Rates of daily use are on the rise

What are the short-term affects of cannabis use disorder?

• Feelings of relaxation and sociability; rapid shifts of emotion

• Interferes with attention, memory and thinking

• Heavy doses can induce hallucinations and panic

• Bloodshot and itchy eyes; dry mouth and throat

• Increased appetite

• Possible temporal disintegration

What is temporal disintegration?

trouble detaining and organizing information

What are the long-term effects of cannabis use disorder?

• tolerance effects ambiguous - may occur with habitual use

• Withdrawal symptoms unlikely among occasional smokers

• Prolonged heavy use may lead to performance deficits on neuropsychological tests - especially sustained attention, learning and decision making

• Damage to lung structure and function in long-term users

What are the therapeutic effects of marijuana?

• Reduces nausea and loss of appetite caused by chemotherapy

• Relieves and discomfort of illnesses such as chronic pain, AIDs, cancer

What are the Supreme Court rulings regarding Cannabis Use Disorder?

• Federal law prohibits dispensing marijuana for medicinal purposes

• Medical use can be prohibited by federal government even if states approve

• As of 2021, 39 states plus District of Columbia, Puerto Rico, Guam, Northern Mariana Islands and US Virgin Islands have approved the use of marijuana for medicinal purposes

• As of 2025, 24 states and several territories have approved adult use of cannabis

What do hallucinogens do?

cause people to experience hallucinations

• colorful visual hallucinations

• psychedelic trip: expansion of consciousness

• Only 1-2% regular users

What are common hallucinogens?

• LSD: most common

• Mescaline: active ingredient of peyote

• Psilocybin: extracted from mushroom psilocpbe Mexican

• MDMA (ecstasy) and Molly: “club drugs”

• PCP: originally developed as a pain killer

What are the short-term effects of hallucinogens and related drugs?

Difficult to study empirically because the effects are based in primarily subjective experience

What are the long-term consequences of hallucinogens and related drugs?

• Use follows different pattern than with most other drugs

• Hallucinogens typically used sporadically and on special occasions, rather than continuously (except PCP)

• No withdrawal; symptoms associated with hallucinogens

• Some people who take them experience flashbacks

What is the frequency of substance abuse disorder?

• Use of specific drugs is determined, in part, by their availability

• Culture shapes people’s choices about the use of drugs and way in which drugs are used

• Many people who use drugs do not become dependent

• It is impossible to specify typical course for substance disorders, especially alcohol use disorders

  • Periods of heavy use alternate with periods of relative abstinence, however short-lived they may be

What is the prevalence of alcohol use disorder?

• approximately 2 out of every 3 males in Western countries drink alcohol regularly, at least on a social basis

  • Less than 25% abstain from drinking completely

• Among all men and women who have ever used alcohol, about 20% will develop serious problems

• Fewer women develop alcohol use disorder compared to men - less of a difference than 50 years ago

• Single standard dose of alcohol will produce a higher peak blood alcohol level in women than in men

  • Measured in proportion to total body weight

Prevalence of tobacco use disorder?

• Lifetime prevalence of nicotine dependence reported to be around 24%

• Percentage of adults in the United States who smoke tobacco has declined since 1964

  • However, recent use of other tobacco products (e.g., smokeless, e-cigarettes) is on the rise

  • Vaping has become a major public health concern as it has rapidly become a preferred way to ingest nicotine

What is the risk for addiction across the life span?

• Drinking alcohol before the age of 14 increases risk for developing alcohol use disorder for men and women

• Prevalence rates higher among young adults and lower among elderly

• Elderly infrequently use illegal drugs - more likely to abuse prescription drugs

• Drug use has different consequences on elderly lives

  • Tolerance is reduced with age

  • Withdrawal may be more severe

What is the comorbidity for substance abuse disorders?

• The most common disorders are antisocial personality disorder, mood disorders, and anxiety disorders

• Conduct disorder is related to concurrent alcohol use in adolescence

• Sometimes depression and anxiety precede the substance use problem

What are the causes of substance abuse disorders?

• Biological Factors

• Psychological Factors

• Social Factors

• Integrated Systems

What are the biological factors?

• Genetics

• Neurobiological Factors

What role do genetics play?

• Relatives and children of problem drinkers have higher-than-expected rates of alcohol abuse or dependence

• Greater concordance in identical than fraternal twins for alcohol use disorder

• Ability to tolerate large quantities of alcohol may be an inherited diathesis

What role do neurobiological factors play?

• Dopamine and Reward Pathways

  • Nearly all drugs, including alcohol, stimulate the dopamine system in the brain

  • Produce rewarding or pleasurable feelings

  • Some evidence that people dependent on drugs or alcohol have deficiency in specific dopamine receptors

What are the psychological factors?

• Expectations about drug effects

• Mood alteration

• Personality

What role do expectations about drug effects play?

• People who expect alcohol to reduce stress and anxiety are most likely to drink

• Positive expectancies about alcohol are especially influential - are likely to encourage people to drink

What role does mood alteration play?

• User desires reduced tension feels from imbibing substance

  • However, tension reduction may be due to “alcohol myopia”

  • User focuses reduced cognitive capacity on immediate distractions

  • Less attention focuses on tension-producing thoughts

  • Effect similar for smoking

What role does personality play?

• Personality factors that predict onset of substance-related disorders:

  • Negative affect

  • Desire for increased arousal and positive affect

  • Low constraint (impulsive)

• Kindergarten children who were rated high in anxiety and novelty seeking more likely to get drunk, smoke, and use drugs in adolescence

What are the social factors?

• Availability

• Advertising and Media

• Family environment

• Experimentation

• Social Network

What role does availability play?

• Alcohol is the most commonly abused substance worldwide

• Usage is higher when alcohol and drugs are easily available

  • Drug use among youths who have been approached by drug dealers is significantly higher than use among youth who have not

What role does advertising and media play?

less consumption of substance in countries that ban ads than those that don’t

What role does family environment play?

• Parental modeling of appropriate versus inappropriate use of alcohol

• Parental alcohol abuse

• Marital discord, psychiatric or legal problems in the family linked to substance use

• Lack of emotional support from parents increases use of cigarettes, marijuana and alcohol

• Lack of parental monitoring linked to higher drug usage

• High levels of negative affect in the home

What role does experimentation play?

Positive attitude towards substances leads to experimentation which can then lead to regular use then heavy use, etc.

What role does social network play?

Having peers that drink influences drinking behavior but also choose friends with drinking patterns similar to their own

What role do integrated systems play?

• Initial experimentation

• Access to drugs

• Short-term positive effects act as reinforcers

• Genetics

• Stimulation of brain’s reward pathway

What are the different forms of treatment?

• detoxification

• medications

• self-help groups - AA

• CBT

What is detoxification?

• Removal of the drug under medical supervision

• Experienced marked withdrawal symptoms

• May be given various medications as a way of minimizing withdrawal symptoms

What medications are used in treatment?

• Typically given during remission

  • Disulfiram (Antabuse): causes violent illness if alcohol is consumed

  • Naltrexone (Revia): may dampen cravings

  • SSRIs (Fluoxetine): antidepressant

  • Synthetic narcotics (Methadone): wean users off of heroin

What do self-help-groups do in treatment - AA?

• Original 12-step program - largest self-help group for problem drinkers

• Regular meetings provide support, understand, and acceptance

• Promotes complete abstinence

• Fundamentally spiritual

• Difficult to evaluate its efficacy - long-term follow up difficult; early dropout

• Appears to help people; its not clear how it helps or why

What role does CBT play in treatment

• Coping skills training

• Relapse Prevention

• Motivation Interviewing

What is coping skills training?

• Anger management focuses on factors that create and maintain drinking

• Addresses negative patterns of thinking, expectations

what is relapse prevention?

• Strategies to prevent relapse - relapse can be almost expected

• Focus on increasing sense of control of one’s life

• Adaptive coping skills

• Addresses abstinence violation effects

What are abstinence violation effects?

guilt and perceived loss of control that person feels when imbibes after extended period of abstinence

What is motivational interviewing (MI) therapy?

• Many people do not take full advantage of treatment opportunities

• Nonconfrontational procedure to resolve ambivalence about use and change behavior

• Recognize inconsistency between behavior and long-term goals

• Primary goal is to increase awareness of the substance use problems

Does the DSM-5-TR include gambling?

Yes its called pathological gambling with substance-related and addictive disorders

What are the two different types of pathological gambling?

• Social gambling : recreational

• Professional gambling: an occupation

What are pathological gambling symptoms?

• Impaired control of gambling actives

• Social impairment following gambling

• Chasing losses, difficult to distinguish from tolerance effects

• Withdrawal-like symptoms when people stop/cut back gambling

What is the diagnosis for a gambling disorder?

• Resemble criteria from alcohol use disorder

• Gambling with increasing larger amount of money to experience the same level of stimulation (similar to tolerance)

• Becoming annoyed/agitated when gambling stops (similar to withdrawal)

• Chasing losses, lying to cover gambling, financially dependent on others for gambling

What is the frequency for gambling disorder?

• Lifetime prevalence in US and European countries is about 2%

• Could be more with speed of legalized gambling

• Men are more likely than women to be pathological gamblers