University Study Notes: Substance-Related and Addictive Disorders

Case Report: Carl Wadsworth

• Demographic Information:     * Patient: Carl Wadsworth, $32$-year-old African American heterosexual cisgender man.     * Pronouns: $he/him/his$.
• History of Present Illness:     * Carl was referred to therapy by his sister, Sharon, due to his family's concern over his heavy alcohol use and a recent arrest for public intoxication.     * Carl has a diagnosis of Bipolar Disorder ($at age 18$) but was non-compliant with his medication (lithium) at the time of intake.     * Carl presented as intoxicated to the first three therapy sessions, initially denying it but later admitting it was "just a little."     * Critical incidents: After an attempt to quit, Carl experienced severe withdrawal symptoms and a subsequent manic episode ($3$ days of no sleep, racing thoughts). He drove Sharon’s car to buy whiskey, consumed the bottle in minutes, and crashed into a lamppost, resulting in a DUI arrest.
• Psychiatric and Social History:     * Parents are former alcoholics.     * Carl lost his telecom job at age $28$ due to downsizing and attempted suicide; he was hospitalized for $1$ month.     * He later worked at a liquor store, where he began drinking with his boss to fit in, eventually stopping his lithium to drink more heavily.     * Progression: Began drinking immediately upon awakening and while at work; eventually fired for threatening a customer.
• Diagnosis and Formulation:     * Dual Diagnosis: Alcohol Use Disorder (Severe) and Bipolar I Disorder.     * Distinction: The alcohol use was determined to arise independently of mood symptoms initially, but exacerbated during manic episodes.
• Risk and Treatment Plan:     * Risk Level: Low-moderate (recent passive ideation, history of attempt, job loss).     * Protective Factors: Family support and willingness to engage.     * Plan: Attend Alcoholics Anonymous (AA) daily, weekly psychotherapy, and consult a psychiatrist for non-lithium mood-stabilizing medication.

Key Features of Substance Disorders

• Definitions:     * Substance: A chemical that alters mood or behavior when smoked, injected, drunk, inhaled, snorted, or swallowed.     * Substance Use Disorder (SUD): A cluster of cognitive, behavioral, and physiological symptoms indicating continued use despite significant life problems.
• Diagnostic Categories (Four Tiers):     1. Loss of Control: Taking larger amounts than intended, inability to cut down, spending extensive time to obtain the drug, and craving.     2. Social Impairment: Neglecting work/family obligations and persistent interpersonal problems.     3. Risky Use: Using in dangerous situations (e.g., driving) or despite known health risks.     4. Pharmacological Changes:         * Tolerance: Requiring higher doses for the same effect.         * Withdrawal: Specific physiological/psychological symptoms occurring after stopping use.
• DSM-5-TR Nomenclature:     * Replaced "abuse" and "dependence" with the single term "substance use disorder."     * Severity ratings: Mild ($2-3$ symptoms), Moderate ($4-5$ symptoms), or Severe ($6+$ symptoms).     * Caffeine Withdrawal: Now a formal clinical diagnosis due to evidence of functional impairment (e.g., headaches, motor performance decline).

Global and National Prevalence Stats

• General Illicit Drug Use (2019):     * Approximately $57.2 \text{ million}$ ($20.8$%) Americans aged $12+$ used illicit drugs in the past year.     * Marijuana: Most common substance ($48.2 \text{ million}$ or $17.5$% reporting use).
• Demographic Variations:     * Race/Ethnicity (Monthly use): American Indians/Alaska Natives ($17.4$%), Black/African American ($13.7$%), Whites ($12$%), Hispanic/Latinx ($9.7$%), Asian ($6.7$%).     * Gender: Males ($14$%) vs. Females ($9.5$%).     * Age: Peak usage at ages $18-25$ ($39.1$%); lowest at age $65+$ ($5.7$%).
• Comorbidity:     * $3.6 \text{ million}$ adults have both an SUD and a psychological disorder.     * Veterans: Alcohol use disorder prevalence is $65$% among those seeking treatment, more than double the general population.     * Incarcerated populations: Alcohol use disorder rates up to $51$% in men.

Alcohol Use Disorders

• Epidemiology:     * $7^{th}$ leading cause of death worldwide.     * Accountable for $2$% of female deaths and $6-8$% of male deaths globally.
• Definitions of Use Patterns:     * Binge Drinking: Women ($4+$ drinks/occasion), Men ($5+$ drinks/occasion).     * Heavy Drinking: Binge drinking on $5$ or more days in the past month.
• Physiological Impact:     * Alcohol acts as a nervous system depressant.     * Potentiation: The mechanism where the effect of two drugs (e.g., alcohol and a sedative) taken together is greater than the sum of their individual effects.     * Metabolic Rate: The average person metabolizes alcohol at a rate of roughly $1/3 \text{ oz}$ of $100$% alcohol per hour (equivalent to $1 \text{ oz}$ of whiskey).
• Neurological Damage:     * Wernicke’s Disease: Acute, reversible condition characterized by delirium, eye-movement issues, and balance problems; caused by Thiamine ($Vitamin B_1$) deficiency.     * Korsakoff’s Syndrome: Permanent neurocognitive disorder involving retrograde amnesia (loss of past memory) and anterograde amnesia (inability to form new memories); recovery rate is less than $1 \text{ in } 4$.

Theories and Treatment of Alcohol Use Disorders

• Biological Perspective:     * Heritability: Estimated between $50$% and $60$%.     * Medications:         * Naltrexone: An opioid receptor antagonist; blocks pleasure from alcohol.         * Disulfiram: Aversion therapy; inhibits enzymes that break down acetaldehyde, causing vomiting, racing heart, and dizziness if alcohol is consumed.         * Acamprosate: Amino acid derivative; moderates glutamate to reduce the urge to drink.
• Psychological Perspective:     * Dual-Process Theory: System $1$ (fast, automatic impulses) vs. System $2$ (slow, controlled processing). SUD occurs when System $1$ overrides System $2$.     * Alcohol Myopia Theory: Alcohol narrows attentional focus, making immediate temptations more powerful than long-term consequences.     * Assessment: The AUDIT (Alcohol Use Disorders Identification Test) is a $10$-question self-report tool.
• Sociocultural Perspective:     * Acculturation: "Americanization" of immigrant groups (Hispanic/Asian) scales with increased binge drinking.     * The SAAF Program: (Strong African American Families) A $7$-week prevention program for youth ($10-14$) focusing on racial socialization and values.

Stimulants and Other Drugs of Abuse

• Amphetamines:     * Speed up CNS; medical uses include treatment for ADHD and obesity.     * Methamphetamine: Highly addictive; causes "meth mouth" and brain damage (down-regulation of dopamine receptors).
• Cocaine:     * Blocks the removal of dopamine from the synapse (particularly in the Ventral Tegmental Area/VTA), amplifying the reward signal.     * Crack is the crystal form for smoking; high is intense but brief ($5-10 \text{ minutes}$).
• Cannabis:     * Active ingredient: Delta-$9$-tetrahydrocannabinol (THC).     * Mechanism: Acts on cannabinoid receptors in brain areas for pleasure, memory, and concentration.     * Cognitive Effects: Acute use impairs attention/concentration; long-term use impairs decision-making.
• Hallucinogens:     * LSD: Causes synesthesia ("hearing" colors/"seeing" sounds) and intense mood swings.     * Peyote: Contains mescaline; used in Native American religious ceremonies.     * PCP: Developed as an anesthetic; causes dissociation and symptoms mimicking schizophrenia.     * MDMA (Ecstasy): Synthetic drug; increases serotonin, norepinephrine, and dopamine. Neurotoxic to serotonin transporters.
• Opioids:     * Incudes Heroin, Fentanyl, and prescription meds (OxyContin, Vicodin).     * Opioid Crisis: $115$ U.S. adults die daily from overdoses; economic burden is approximately $\$78.5 \text{ billion}/year$.     * Treatment: Methadone (binding same receptors), Buprenorphine (lower overdose risk), or Extended-release naltrexone.
• Sedatives, Hypnotics, and Anxiolytics:     * Increase levels of GABA (inhibitory neurotransmitter) to produce calming effects.     * Includes benzodiazepines and barbiturates.
• Inhalants:     * Diverse vapors (glue, paint thinner, nitrites) that cause hypoxia (oxygen deprivation), potentially killing neurons and damaging the myelin sheath.

Non-Substance-Related Disorders

• Gambling Disorder:     * Included with SUDs because it triggers similar reward pathways and involves cravings.     * Behavioral Mechanism: Operates on a variable-ratio reinforcement schedule (high resistance to extinction).     * Cognitive Distortions:         * Gambler’s Fallacy: Thinking a "black" outcome is due because "red" hit four times.         * Illusion of Control: Overestimating personal influence over random events.     * Pathways Model:         1. Behaviorally Conditioned: Developed via exposure and distorted cognitions.         2. Emotionally Vulnerable: Used to cope with preexisting trauma/depression.         3. Antisocial Impulsivist: Driven by thrill-seeking and impulsivity.

Case Study: Mary J. Blige

• Background: Raised in the Bronx/Georgia; sexually assaulted at age $5$.
• Addiction: Used alcohol and cocaine to "numb" abandonment issues and trauma memories.
• Recovery: Motivated by the death of Whitney Houston ($2012$) and spiritual faith. Blige chose a private recovery path over traditional rehab, focusing on her career as a "courageous woman."

Questions & Discussion

• You be the Judge: What is the best way to balance the patient's need for pain relief with the growing national crisis in abuse of prescription pain medications?     * Response Context: The National Institutes of Health (NIH) launched the HEAL (Helping to End Addiction Long-Term) initiative to double funding for non-addicting pain medications. Psychologists emphasize identifying predisposing factors for addiction while managing chronic pain through behavioral measures.