Substance Related Disorder: Substance Abuse and Dependence; Alcohol, Nicotine, Marijuana, Sedatives and Stimulants: Etiology

1. Overview of Substance-Related Disorders in DSM-5

The DSM-5 categorizes substance-related disorders into two main groups:

• Substance Use Disorders (SUDs): A cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.

• Substance-Induced Disorders: These include intoxication, withdrawal, and other substance/medication-induced mental disorders.

The DSM-5 recognizes 10 classes of substances that can lead to SUDs:

1. Alcohol

2. Caffeine

3. Cannabis

4. Hallucinogens

5. Inhalants

6. Opioids

7. Sedatives, Hypnotics, or Anxiolytics

8. Stimulants

9. Tobacco

10. Other (or unknown) substances

2. DSM-5 Diagnostic Criteria for Substance Use Disorders

A Substance Use Disorder is diagnosed when an individual exhibits at least two of the following 11 criteria within a 12-month period:

1. Taking the substance in larger amounts or over a longer period than intended.

2. Persistent desire or unsuccessful efforts to cut down or control use.

3. Spending a great deal of time obtaining, using, or recovering from the substance.

4. Craving or a strong desire to use the substance.

5. Recurrent use resulting in failure to fulfill major role obligations at work, school, or home.

6. Continued use despite persistent social or interpersonal problems caused or exacerbated by the substance.

7. Giving up or reducing important social, occupational, or recreational activities because of use.

8. Recurrent use in situations where it is physically hazardous.

9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by the substance.

10. Tolerance, as defined by either:

    • A need for markedly increased amounts to achieve intoxication or desired effect.

    • A markedly diminished effect with continued use of the same amount.

11. Withdrawal, as manifested by either:

    • The characteristic withdrawal syndrome for the substance.

    • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

Severity Specifiers:

• Mild: 2–3 symptoms

• Moderate: 4–5 symptoms

• Severe: 6 or more symptoms

3. Specific Substance Use Disorders

A. Alcohol Use Disorder (AUD)

• Clinical Picture:

  • Frequent consumption leading to intoxication.

  • Neglect of responsibilities.

  • Continued use despite interpersonal problems.

  • Development of tolerance and withdrawal symptoms.

• Withdrawal Symptoms:

  • Tremors, insomnia, nausea, hallucinations, anxiety, seizures.

B. Nicotine Use Disorder

• Clinical Picture:

  • Compulsive tobacco use.

  • Difficulty quitting despite health issues.

  • Cravings and withdrawal symptoms upon cessation.

• Withdrawal Symptoms:

  • Irritability, anxiety, difficulty concentrating, increased appetite.

C. Cannabis Use Disorder

• Clinical Picture:

  • Frequent use leading to tolerance.

  • Use in hazardous situations.

  • Continued use despite social or interpersonal problems.

• Withdrawal Symptoms:

  • Irritability, sleep difficulties, decreased appetite, restlessness.

D. Sedative, Hypnotic, or Anxiolytic Use Disorder

• Clinical Picture:

  • Use of medications like benzodiazepines beyond prescribed amounts.

  • Development of tolerance and withdrawal.

  • Continued use despite negative consequences.

• Withdrawal Symptoms:

  • Anxiety, insomnia, seizures, tremors.

E. Stimulant Use Disorder

• Clinical Picture:

  • Use of substances like amphetamines or cocaine leading to euphoria.

  • Increased energy followed by crashes.

  • Risky behaviors and potential for cardiovascular issues.

• Withdrawal Symptoms:

  • Fatigue, depression, sleep disturbances, increased appetite.

4. Etiology of Substance Use Disorders

The development of SUDs is multifactorial, involving a combination of biological, psychological, and social factors.

A. Biological Factors

• Genetics:

  • Family history increases risk.

  • Twin studies suggest heritability.

• Neurobiology:

  • Alterations in brain reward pathways, particularly involving dopamine.

  • Changes in brain structures related to decision-making and impulse control.

B. Psychological Factors

• Personality Traits:

  • Impulsivity, sensation-seeking behavior.

• Co-occurring Mental Disorders:

  • Depression, anxiety, PTSD can increase vulnerability.

• Coping Mechanisms:

  • Substance use as a maladaptive strategy to cope with stress or trauma.

C. Social and Environmental Factors

• Peer Influence:

  • Association with substance-using peers.

• Socioeconomic Status:

  • Poverty, lack of access to education and healthcare.

• Cultural Norms:

  • Societal attitudes towards substance use.

• Availability:

  • Ease of access to substances.

5. Treatment Approaches

Effective treatment often requires a combination of interventions:

• Behavioral Therapies:

  • Cognitive-behavioral therapy (CBT), motivational interviewing, contingency management.

• Pharmacotherapy:

  • Medications like methadone for opioids, nicotine replacement therapy for tobacco.

• Support Groups:

  • 12-step programs like Alcoholics Anonymous (AA), Narcotics Anonymous (NA).

• Integrated Treatment:

  • Addressing co-occurring mental health disorders simultaneously.