Substance-Related Disorders
Chapter 11: Substance-Related Disorders
DSM-5 Substance-Related and Addictive Disorders
Types of Disorders:
Alcohol-related disorders
Caffeine-related disorders
Cannabis-related disorders
Hallucinogen-related disorders
Inhalant-related disorders
Opioid-related disorders
Sedative, Hypnotic-, or Anxiolytic-related disorders
Stimulant-related disorders
Tobacco-related disorders
Non-substance-related disorders (e.g., gambling disorder)
Introduction
Definitions:
Substance abuse: Excessive use of a substance.
Substance dependence: Physiological need for increasing amounts of a substance.
Tolerance: Biochemical changes in the body resulting in reduced effects from the same amount of a substance.
Withdrawal: Physical symptoms resulting from abstinence of substance use.
DSM-5 Substance-Related Disorders: Pathological patterns of behavior related to particular substance use.
Symptoms of Substance Use Disorder
Diagnosis requires 2 or more of the 11 addiction symptoms:
Withdrawal: Experiencing withdrawal symptoms or using to prevent these symptoms.
Tolerance: Needing to consume more of the substance to achieve similar effects.
Difficulty controlling the amount consumed.
Failure to abstain from use after attempts to quit.
Failure to fulfill major life obligations due to substance use.
Significant reduction in social or recreational activities.
Social conflicts arising from use of the substance.
Engaging in dangerous activities while under the influence (e.g., driving).
Significant time spent on activities related to obtaining, using, and recovering from the substance.
Cravings for the substance.
Continuing to use despite causing or worsening a physical or psychological condition.
DSM-5 Criteria for Substance-Related Disorders
Specifiers for diagnosis:
In early remission: 0 criteria met for 3-12 months (craving can persist).
In sustained remission: 0 criteria met for 12+ months (craving can persist).
Severity Specifiers:
Mild: 2-3 symptoms
Moderate: 4-5 symptoms
Severe: 6+ symptoms
Learning Objectives
11.1: Characteristics of alcohol abuse and dependence.
11.2: Biological, psychosocial, and sociocultural factors involved in alcohol use disorder.
11.3: Treatment of alcohol-related disorders.
11.4: Psychoactive drugs commonly associated with substance use disorder.
11.5: Commonly used opiates and their body effects.
11.6: Different types of stimulants and their effects.
11.7: Effects of sedatives on the brain.
11.8: Four types of hallucinogens.
11.9: Addictive disorders beyond alcohol and drugs.
Alcohol Abuse and Dependence
Definition of Heavy episodic drinking (According to WHO):
5-6+ drinks on one occasion (as determined by SAMHSA in 2016).
Individual differences in processing alcohol and tolerance levels not accounted for (i.e., % blood alcohol level).
Prevalence, Comorbidity, and Demographics of Alcohol Abuse and Dependence
General Considerations:
Alcohol abuse cuts across all demographic boundaries (age, education, occupation, and socioeconomic status).
Lifetime prevalence of alcohol abuse or Alcohol Use Disorder (AUD) in the U.S. is about 30%.
Enormous detrimental physical effects associated with alcohol abuse, including links to accidents and violent crime.
No significant demographic differences in alcohol abuse among Black and White Americans.
Indigenous peoples of the Americas report higher rates of alcohol use problems.
Rates of abuse vary significantly between countries.
More than 37% of individuals with alcohol use disorders also suffer from at least one co-occurring mental disorder.
Racial and Ethnic Comparisons
Regarding alcohol abuse, no significant differences are noted between Black and White Americans.
Indigenous peoples of the Americas experience higher rates of alcohol abuse compared to their counterparts.
Overall rates of alcohol abuse among various racial and ethnic groups vary across different countries.
Gender Differences in Alcohol Use Disorder
Risk Ratio: For men vs. women regarding risk for AUD is 2:1.
These differences are narrowing, although reasons remain unclear.
Weighted point prevalence rates of AUD were analyzed from 2009-2019 (as reported by Verplaetse et al., 2025).
Clinical Picture of Alcohol-Related Disorders
Alcohol has complex effects on the brain:
At lower consumption levels, alcohol can stimulate certain brain cells and activate the dopaminergic "pleasure areas", leading to a false sense of well-being and euphoria.
At higher levels, it depresses the nervous system, inhibiting glutamate (an excitatory neurotransmitter), which deteriorates judgment and decision-making skills.
Alcohol impacts the cerebellum, affecting balance and coordination.
"Passing out" typically occurs around 0.50% Blood Alcohol Concentration (BAC), while lethal levels start at around 0.55% BAC. Alcohol levels can still increase in unconscious individuals, which represents a serious risk for poisoning.
Physical Effects of Chronic Alcohol Use
Malnutrition:
Appetite reduction due to alcohol use.
Impaired nutrient absorption in the liver may lead to alcohol amnestic disorder.
Cirrhosis of the Liver:
Resulting in stiffening of blood vessels.
Stomach Pain: A common complaint among chronic users of alcohol.
Biological Factors in Alcohol Use Disorder (AUD)
Neurobiology of Addiction:
The Mesocorticolimbic pathway is crucial for the pleasure and reward response to psychoactive drugs.
Genetic Vulnerability:
Genetic inheritance from biological parents can increase risk.
Personality traits such as impulsivity and emotional instability are contributing factors.
Differences in race/ethnicity can affect the metabolism of alcohol.
Numerous genetic aspects and their implications for addiction still remain subjects for exploration.
Psychological Factors in Alcohol Use Disorder (AUD)
Failures in Parental Guidance:
Lack of stable family relationships can impact the likelihood of substance abuse.
Exposure to dysfunctional family models can increase future risks of alcohol use.
Comorbidity:
Alcohol abuse correlates highly with mental disorders and should be factored into treatment planning.
Motives/Expectancies for Substance Use:
Coping Mechanism: Individuals may turn to alcohol for stress and tension relief.
Social Acceptance: Expectations regarding social interactions can influence consumption.
Marital and Other Intimate Relationships:
Crises in personal relationships often contribute to excessive drinking and vice versa.
Sociocultural Factors in Alcohol Use Disorder (AUD)
Group Attitudes:
Societal attitudes towards drinking can impact individuals (e.g., positive vs. negative perceptions of alcohol consumption).
Common Social Lifestyles:
Scenarios such as college campuses exhibiting binge drinking tendencies; social networks frequently impact perceptions regarding the normalcy of heavy drinking.
Treatments for Alcohol-Related Disorders
Medications:
Medications to block the desire to drink:
Disulfiram (Antabuse): Causes illness upon alcohol consumption.
Naltrexone: Blocks feelings of euphoria associated with alcohol consumption.
Medications to alleviate withdrawal side effects:
Tranquilizers, which have associated risks.
Psychological Treatment:
Group therapy ensures individuals confront and own up to their issues.
Environmental intervention includes promoting social changes or residential living arrangements.
Behavioral and cognitive-behavioral therapy techniques such as aversion therapy, skills training, and self-monitoring of triggers.
Alternative Approaches:
Controlled drinking instead of complete abstinence, especially for mild problems (though this is controversial).
Alcoholics Anonymous: Emphasizes a disease model and a twelve-step recovery plan; focused on spiritual aspects and accountability.
Success Rates:
Motivational interviewing and relapse prevention programs are cited to be effective strategies.
Conclusion
Ongoing research and treatment adaptations for alcohol-related disorders are paramount as understanding the biological, psychological, and sociocultural factors is crucial for effective management and intervention for individuals with substance use disorders.