Substances

 

 

Substance-Related Disorders

1. Introduction to the Substance-Related Disorders

  • The Substance-Related Disorders include disorders brought about by taking the drug of abuse (including alcohol), the side effects of a medication, or by the exposure of toxins. In the DSM-IV, the word substance can refer to a drug of abuse, a medication, or a toxin one is exposed to (4th ed., text rev.; DSM–IV–TR; American Psychiatric Association, 2000).
  • Substance-Related Disorders involve various forms of indulgence of drugs or chemicals that could lead to the demise of an individual’s physical or mental health status. A substance use disorder can affect anyone; rather they be rich or poor, male or female, employed or unemployed, young or old, and any race or ethnicity. The etiology is unknown, however; the chance of developing a substance use disorder depends partly on genetics, which are biological traits passed down through families. Although person’s environment, psychological traits, and stress level can also play a significant role in the use of alcohol or drugs. These substances can include nicotine in the form of tobacco, alcohol, hallucinogens, steroids, inhalants as well as opioids. The use of these substances can affect cognitive, behavioral, and psychological symptoms that occur due to repetitive use and abuse of the substance that can often lead to tolerance, withdrawal, and dependency. An individual’s need to continue to use the substances despite their awareness of negative side affects is a key factor in determining dependency. They feel like they have to use the substance to function day to day in society. There are many documentaries that have been made revealing the seriousness of substance use, case in point the new MTV documentary “Steve-O Demise and Rise“.

2. Substance Abuse vs. Substance Dependence

  • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
  1. 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
  1. withdrawal, as manifested by either of the following:
  • (a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
  • (b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
  1. the substance is often taken in larger amounts or over a longer period than was intended
  2. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
  4. important social, occupational, or recreational activities are given up or reduced because of substance use
  5. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
  • Specify if:
  1. With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either item 1 or 2 is present)
  2. Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither 1 nor 2 is present)
  • Course specifiers:
  1. Early Full Remission
  2. Early Partial Remission
  3. Sustained Full Remission
  4. Sustained Partial Remission
  5. On Agonist Therapy
  6. In a Controlled Environment
  • DSM-IV-TR Substance Abuse Criteria:
  • A. A maladaptive pattern of substance use leading to clinically significant impairment of distress, as manifested by one (or more) of the following, occurring within a 12-month period:
  1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
  4. continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  • B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
  • Epidemiology
  • Alcohol use reportedly has been on the decline in recent years. Reports indicate that roughly two thirds of all adults drink alcohol occassionally. Approximately 13% of people in the US are alcoholics, and 1 person in 5 who uses alchol for recreational purposes becomes dependent for some period of time. Studies perfomed in urban EDs indicate that up to 20% of patients may have problems with alcohol, with the highest rate in patients who present late at night. In contrast to alcohol use, heroin use is rising. Estimates place the number of heroin users in the US at 750, 000. Heavy cocaine use has remained fairly steady since its peak in the late 1980s and early 1990s, with an estimated 600,000-700,000 regular users. On the rise in rural communities is use of methamphetamine, also known as crystal meth. It is easily manifactured as the base ingredient is over-the-counter cold medication. It is found to be abused most often in the 15-to-25-year-old age bracket. Abuse of prescription and over-the-counter drugs is rapidly increasing, especially in teenagers.
  • LINKS:

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3. Substance intoxication

  • DSM-IV-TR Substance Intoxication Criteria
  • A. The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance. NOTE: different substances may produce similar or identical syndromes.
  • B. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (e.g., belligerence, mood liability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and development during or shortly after use of the substance.
  • C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

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4. Substance Withdrawal

  • DSM-IV-TR Substance Withdrawal criteria
  • A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and
  • prolonged.
  • B. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of
  • functioning.
  • C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
  • Links
  • DSM-V Proposed Changes:
  • Adding “Substance-Use Disorder”
  • DSM-V Criteria for Substance-Use Disorder
  • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
  1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  4. 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
  • (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
  1. withdrawal, as manifested by either of the following:

a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

  • b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  • (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
  1. the substance is often taken in larger amounts or over a longer period than was intended
  2. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  4. important social, occupational, or recreational activities are given up or reduced because of substance use
  5. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  6. Craving or a strong desire or urge to use a specific substance.

Severity specifiers:

  • Moderate: 2-3 criteria positive
  • Severe: 4 or more criteria positive
  • Specify if:
  • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
  • Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)
  • Course specifiers (see text for definitions):
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • On Agonist Therapy
  • In a Controlled Environment

5.Hallucinogen Dependence (304.5) and Hallucinogen Abuse (305.3).

  • Hallucinogen Dependence – DSM-IV-TR criteria
  • One of the generic Dependence criteria (i.e., withdrawal) does not apply to hallucinogens, and others require further explanation. Tolerance has been reported to develop rapidly to the euphoric and psychedelic effects of hallucinogens but not to the autonomic effects such as pupillary dilation, hyperreflexia, increased blood pressure, increased body temperature, piloerection, and tachycardia.
  • Specify if:
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • In a Controlled Environment
  • Hallucinogen Abuse – DSM-IV-TR criteria
  • Individuals may use hallucinogens in situations that are physically hazardous (e.g., while driving a motorcycle or a car) and/or repeatedly fail to fulfill obligations at school, home, or work due to behavioral impairments caused by Hallucinogen Intoxication. There may be recurrent social or interpersonal problems due to the individual’s behavior while intoxicated, isolated lifestyle, or arguments with significant others.
  • Associated features
  • Individuals with hallucinogen dependency continue to use hallucinogens even when they are aware of the adverse effects of the drug as well as the impact on his/her life. They report “craving” hallucinogens after not using them for a period of time (It should be noted that these are psychological addictions, as hallucinogens do not create a physiological dependency). So the individual just wants the substance really bad, but is not dependent on it physically. Individuals with hallucinogen abuse continue to use hallucinogens in spite of certain cases of impairment that disable them from fulfilling obligations in their work, home, etc. This is when you know that it has a major effect on the individual when they are inhibited in most daily activities and obligations such as school duties, work, home chores, and even routine stuff such as hygiene and other motor activities. Hallucinogen use by “abusers” is generally less frequent than those with dependency. Abusers just use when a particular substance is readily available and easy to obtain, for example, if a friend is in possession of that substance. Dependent individuals need that certain substance to get a “fix” on themselves to assure themselves that they are normal. This helps the person in stressful situations in which they feel uncomfortable and think they have to do these behaviors to be or act normal.
  • In Hallucinogen Dependence, withdrawal does not apply, but the person may have mental cravings for a substance. With Hallucinogen Abuse, one is likely to use less often; however, they may have a tendency to fail to fulfill certain obligations, and have legal, social and interpersonal problems that have to do with societal functions. Individuals with hallucinogen dependence tend to have a blurring of the senses, a loss of appetite, distortions, tachycardia, dilated pupils, and nausea.
  • Child vs. adult presentation
  • There is no differentiation between child and adult presentation because it is dependent upon consumption of the substance and not from psycho developmental causes. The amount of substance consumed is generally more for the adults than the children with a particular substance mainly because of low body weight and a low tolerance level.
  • Gender and cultural differences in presentation
  • While there are no significant differences between gender and use, it has been found that these disorders are much more prevalent in cultures where there are “raves,” dance clubs, and other similar social settings where hallucinogens are common. There is move from recreational use to disorder is determined by cultural and social contexts; what is acceptable depends on what society it occurs in. Norms are defined by how a society defines addiction. Majority of research is on males because they are overall more likely to use and abuse psychoactive substances. Women use more in response to current stressful situations and are more likely to have used a substance preceded by another mental disorder. Women users are seen as more promiscuous and more likely to be a victim of a violent crime. There is a stigma attached to women who use because people view it as socially unacceptable. They generally do not reveal their problems on their own, an intervention is likely to help recover. Female users appear not to respond as well to treatments, family support and other numerous factors.
  • Epidemiology
  • Hallucinogen dependency is considered more rare than abuse. Only 2-3% of people who recurrently use hallucinogens become dependent upon them. Abuse is not as rare and a little more common because the amount of time required to abuse rather than depend on a substance is less. To abuse a substance, a person just uses it and eventually will want to do it again, and it is usually followed by some form of dependence. This would involve wanting the substance on a regular basis, and if not in possession of said substance, some aggressive, stress reaction would follow; it could also be in the form of violent behaviors that would end up hurting others close to you.
  • Etiology
  • The causes of hallucinogen dependency and abuse are difficult to pinpoint, as they are purely psychological addictions. Self-esteem, self-worth, and history with other substance use are the best indicators of one’s susceptibility to hallucinogen dependence and/or abuse. When a person uses drugs it makes it more likely that they will try other drugs. There is a 40% to 60% risk of alcoholism that is explained by genetic influences. Alcohol dependence is 3-4 times higher in close relatives of people with alcohol dependence. There is reinforcement of substance use because of how it reduces anxiety and tension.
  • Empirically supported treatments
  • In the treatment of one under the influence, Lorexone has been used to mitigate the anxiety attack resulting from a “bad trip.” The treatment of dependency involves extended sessions of psychotherapy. Any underlying physiologic disorders connected to addictive personality, if present, should be addressed and resolved. Pharmacotherapy treatments that have little effect if discontinued are Antabuse, which is naltrexone for alcohol, and Methadone or LAAM for opiates. Co-occurring disorders may be treated medically with antidepressants and SSRI’s, or selective serotonin re-uptake inhibitors. Antipsychotic medicines can also be prescribed to help with the dependency; haloperidol and risperidone are examples of these. Also, certain treatments require the use of self-help groups, such as Narcotics or Alcoholics Anonymous, in order to provide a secure and encouraging environment for the individual.
  • LINKS:

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6. Hallucinogen Intoxication (292.89)

  • DSM-IV-TR criteria
  • A. Recent use of a Hallucinogen.
  • B. Clinically Significant maladaptive behavioral or psychological changes (e.g., marked anxiety or depression, ideas of reference, fear of losing one’s mind, paranoid ideation, impaired judgment, or impaired social or occupational functioning) that developed during, or shortly after, hallucinogen use.
  • C. Perceptual changes occurring in a state of full wakefulness and alertness (e.g., subjective intensification of perceptions, depersonalization, derealization, illusions, hallucinations, synesthesias) that developed during, or shortly after, hallucinogen use.
  • D. Two (or more) of the following signs, developing during, or shortly after, hallucinogen use:
  1. pupillary dilation
  2. tachycardia
  3. sweating
  4. palpitations
  5. blurring of vision
  6. tremors
  7. incoordination
  • E. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
  • Associated features
  • Hallucinogen Intoxication usually begins with some stimulant effects such as restlessness and autonomic activation. Nausea may occur. A sequence of experiences then follows, with higher doses producing more intense symptoms. Feelings of euphoria may alternate rapidly with depression or anxiety. Initial visual illusions or enhanced sensory experience may give way to hallucinations. At low doses, perceptual changes frequently do not include hallucinations. Synesthesias (a blending of senses) may result, for example, in sounds being “seen.” The hallucinations are usually visual, often of geometric forms or figures, sometimes of persons and objects. More rarely, auditory or tactile hallucinations are experienced. In most cases, reality testing is preserved (i.e., the individual knows that the effects are substance induced).
  • Symptoms include distortion of sight, sound, and touch, disorientation, paranoia, anxiety attacks, blissful calm or state of being mellow, increased empathy, long-term memory loss, and impaired concentration and motivation.
  • Physical symptoms include increased blood pressure, increased heart rate, vomiting, blurred vision, enlarged pupils, sweating, diarrhea, restlessness, muscle cramping, dehydration, and increase in body temperature that may lead to seizures.
  • Child vs. adult presentation
  • Gender and cultural differences in presentation
  • Epidemiology
  • Etiology
  • Empirically supported treatments
  • While someone is suffering from Hallucinogen Intoxication it is best to have physical contact with the person, although sometimes adverse reactions do occur to physical touch sometimes it helps to keep the person intact with reality. Helping the intoxicated person to breath slowly and keep them away from large groups of people helps.
  • Links:

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7. Hallucinogen Persisting Perception Disorder (Flashbacks) (292.89)

  • DSM-IV-TR criteria
  • A. The re-experiencing, following cessation of use of a hallucinogen, of one or more of the perceptual symptoms that were experienced while intoxicated with the hallucinogen (e.g., geometric hallucinations, false perceptions of movement in the peripheral visual fields, flashes of color, intensified colors, trails of images of moving objects, positive afterimages, halos around objects, macropsia, and micropsia).
  • B. The symptoms in Criterion A cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • C. The symptoms are not due to a general medical condition (e.g., anatomical lesions and infections of the brain, visual epilepsies) and are not better accounted for by another mental disorder (e.g., delirium, dementia, Schizophrenia) or hypnopompic hallucinations.
  • Associated features
  • Major depression and panic disorders and frequented associated features of HPPD.
  • Child vs. adult presentation
  • Gender and cultural differences in presentation
  • Epidemiology
  • Episodes of self induced abnormal perceptions are associated with HPPD. These episodes can occur simply by thinking about them or can be triggered by stressors such as entry into a dark environment, various drugs, and anxiety or fatigue. These episodes will usually stop or be less frequently occurring after several months. The individual must be able to recognize that the perception is a drug effect and does not represent external reality. A diagnosis of Psychotic Disorder Not Otherwise Specified would be needed if the individual has a delusional interpretation concerning the etiology of the perceptual disturbance.
  • Uncommon, although prevalence rates are higher in larger populations, the amount of people who take hallucinogens and those who suffer from HPPD have no correlation.
  • Etiology
  • No one is completely sure what causes HPPD, although there have been many theories. Many believe that the excessive use of hallucinogen causing drugs do not develop HPPD.
  • Empirically supported treatment
  • HPPD can often times mimic side affects of a stroke, brain tumor, or any other neurological disorder. Antidepressant drugs can sometimes help but there is no certain cure or treatment for HPPD. Psychotherapy helps to reduce anxiety or to help one cope with the hallucinations, but unfortunately there is nothing to take away the actual hallucinations. Benzodiazepines such as Valium or Xanaxcan help to reduce haullucinations as well as the anticonvulsant drug Clonazepam/Klonopin.
  • DSM-V Proposed Changes: Adding “Hallucinogen-Use Disorder”
  • DSM-V Criteria for Hallucinogen-Use Disorder:
  • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
  1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  4. 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
  • (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
  1. withdrawal, as manifested by either of the following:

a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

  • b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  • (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
  1. the substance is often taken in larger amounts or over a longer period than was intended
  2. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  4. important social, occupational, or recreational activities are given up or reduced because of substance use
  5. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  6. Craving or a strong desire or urge to use a specific substance.

Severity specifiers:

  • Moderate: 2-3 criteria positive
  • Severe: 4 or more criteria positive
  • Specify if:
  • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
  • Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)
  • Course specifiers (see text for definitions):
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • On Agonist Therapy
  • In a Controlled Environment

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8. Opioid abuse (305.52)

  • DSM-IV-TR criteria
  • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) (2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of Intoxication, physical fights)
  • B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
  • Associated features
  • Opioids are drugs that include both natural and synthetic substances. The mental effects of an opioid abuser include depression with few or all of its diagnostics, such as selflessness, problems sleeping, lack of interest, faulty coping skills, and even suicidal thought. The effects of opioid abuse are not easily noticeable. The only recognizable observation that could be made is the result of small-sized pupils, or inflamed nasal mucosa if snorted. Although opioid abuse is not as severe as being dependent of opioids, it does however continuously result in negative consequences of using the drug recurrently.
  • Child vs. adult presentation
  • Opioid abuse can arise in both children and adults at any age, yet is most common among young adults roughly starting at about sixteen and older. The age of first use opioid abuse is typically about sixteen years of age, though this age has been dropping over the years. From 2002 to 2007 opioid abuse among young adults (18 & older) rose by more than twelve percent. Although opioid abuse is harmful to the abuser, it can also result in mental injury or death of young children, most often between the ages of three and six.
  • Gender and cultural differences in presentation
  • Opioid abuse among men increased two percent in 2002 to 2.6 percent in 2007 but did not change significantly for females. Men are twice as likely to overdose on pain relievers than women. Males are more likely to abuse opioids than females, with the male-to-female ratio being approximately 1.5:1 for prescription opioids. There is a much higher incidence of opioid-related deaths in rural areas than urban areas.
  • Epidemiology
  • Etiology
  • There are no definite causes of opioid abuse other than initial choice to use the drug, though this choice can be highly influenced by peer pressure. Most opioid abusers typically experience early health problems in life, behavioral problems in early childhood, low self-esteem, and lack of respect for authority figures.
  • Empirically supported treatments
  • There are roughly eight ways to go about treating opioid abuse. These treatments include counseling, medications to reverse the effects of opioids, supportive-expressive psychotherapy sessions, and self-help groups. Opioid abuse treatment is influenced by managed care and is changing rapidly.
  • The psychotherapy sessions try to focus on relapse prevention and cognitive therapy.
  • There are two major types of maintenance therapy. They are methadone and buprenorphine. Methadone has been in use for over 30 years. It acts as an antagonist and replaces the need to daily dose of different types of opioids. It reduces criminal acts and promiscuous behaviors. It is only available at specialty clinics. Buprenorphine is like methadone in reducing cravings. It is safer at higher levels which produce no side effects. It is becoming more popular for this reason. It is also more accessible because it can be used in a doctor’s office.
  • Opioid abuse relapse rates vary from 25%-97%, being higher for those who smoke cigarettes than those who do not. Successful treatments are determined by improvements in social functions, reduction of illicit drug use, and performance at work and school. The success of treatment often varies according to the type of opioid abused and other factors such as medical care, employment, legal situation, family, and psychological difficulties. The chances of a successful recovery from opioid abuse are much higher in those with profession degrees than those with a poor education level and lower income jobs.
  • LINKS:
  • A continunation of Mike’s Story and the medication he used for treatment. Other possible treatments for opioid abuse are listed above. (uploaded by newsinfusion)
  • The following video discusses pharmacological treatments for opioid abuse. Additional treatments are listed above. (uploaded by RickChavezMD)
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9. Sedative, hypnotic, or anxiolytic related abuse and dependence(292.89)

  • DSM-IV-TR criteria
  • A) A Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been heavy and prolonged.
  • B) Two (or more) of the following, developing within several hours to a few days after Criterion A:
  • autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
  • increased hand tremor
  • insomnia
  • nausea or vomiting
  • transient visual, tactile, or auditory hallucinations or illusions
  • psycho-motor agitation
  • anxiety
  • grand or Gran Mal seizures
  • C) The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • D) The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
  • Specify if:
  • With Perceptual Disturbances
  • Associated features
  • Slurred speech or memory loss is very common. If in a working situation, the chances of the abuser missing work or have inconsistent work effort is high. People that abuse alcohol will often have the constant smell of alcohol on their breath. Sedative, hypnotic, or anxiolytic substances can also affect ones family life, bring up more conflicts and arguments, and sometimes even split up a family.
  • Other features include paranoia, trouble sleeping, and putting oneself in hazardous situations, such as driving while intoxicated or high. A result of abuse of drugs can also be coma or some times even death
  • Child vs. adult presentation
  • Although abuse/dependency occurs more in adults than in children, the population of children consuming sedative, hypnotic or anxiolytic substances increases daily. Though children are not addicted to said substances it increases their chances of being dependent on them later on in life
  • Seizures can be seen with the abuse of sedative, hypnotic, or anxiolytic substances. Grand Mal seizures or Gran Mal is a seizure type that is most commonly associated with epilepsy. There are other types that are less known and can occur.
  • Gender and cultural differences in presentation
  • Sedative, hypnotic, or anxiolytic abuse not only appears in the United States, but throughout the world. When it comes to prescription, women have higher chances of becoming addicted than men do. Also, the older the woman is, it increases her chances of substance abuse/dependency.
  • Epidemiology
  • Up to 90% of people in the United States have received some type of sedative, hypnotic, or anxiolytic drug while hospitalized. Over 15% of adult Americans take one or more of these drugs as prescribed medicine. These types of drugs could be benzodiazepines(used for may things such as insomnia, seizures, epilpsy, sedation for surgical procedures, etc., barbiturates (used for epilepsy management, contributes to withdrawal symptoms),other sleeping pills, as well as alcohol.
  • Etiology
  • There are several causation’s for sedative, hypnotic, or anxiolytic abuse/dependency. Some of those reasons include stress or depression. Many times users create an addiction to these drugs because they started abusing them at an early age. Another causation for abuse could be that one was prescribed medicine because of injury, leading to a dependence on said medication.
  • People who are addicted to said drugs have a higher chance of fighting people around them to continue taking the drugs. They will make up excuses as to why they need to take the drug, such as they cannot sleep at night without it, etc.
  • Empirically supported treatments
  • The best form of treatment for sedative, hypnotic, or anxiolytic abuse/dependency would be complete independence from all drugs. This causes users to experience withdrawal that consists of lack of sleep, breaking into sweats, anxiety, vomiting, and sometime even seizures. If the drug is one that takes longer to take effect then its withdrawal takes longer. If it is a drug that may work quickly then withdrawal symptoms with be visual sooner. In March 2007, the United States Food and Drug Administration encouraged the pharmaceutical companies producing sedative-hypnotic drugs to increase their labeling that such abuse of drugs could cause allergic reaction or sleep related behaviors.

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10. Nicotine dependence (305.1)

  • DSM-IV-TR criteria
  • Specifiers:
  • With Physiological Dependence
  • Without Physiological Dependence
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • Nicotine dependence is both a psychological and physical reliance on the drug nicotine that can be found in a variety of tobacco products. Throughout the world, tobacco is one of the most widely used legal substances. Nicotine research indicates that the use of even a small amount can lead to dependency. Even though nicotine has been linked to cancer-related deaths and a myriad of health related issues, an individual who is dependent upon nicotine has difficulty in cessation due to continued compulsions to use the substance. Nicotine, like many of the other substances that are grouped into substance use disorders, can produce a euphoric feeling that alters the mood of the user. These effects can be seen in the individual brain patterns of the user. Regular and normal functioning of a person with nicotine dependency often relies on this substance to complete everyday activities. At the same time, quitting tobacco use causes withdrawal symptoms, including but not limited to irritability and anxiety.
  • Associated features
  • Nicotine comes from the tobacco plant which is dried and used in cigarettes, chewing tobacco, cigars, and pipes. The use of nicotine can generate a feeling of increased alertness or relaxation in the individual. This may also depend on how much a person smokes, the strength of inhalation, and how often the person uses nicotine. The psychological aspects connected with nicotine can be triggered by normal everyday events such as waking up, getting into a car, or finishing a meal. Psychological triggers can occur when an individual is faced with particular situations or issues that make them angry, stressed, anxious, or bored. The physical reliance is related to the functioning of the brain and how nicotine affects it. Certain receptors in the brain cells come to rely on nicotine molecules to enable the normal functioning of an individual on a daily basis.
  • Child vs. adult presentation
  • Children and adolescents often exhibit nicotine dependence symptoms even if they have never smoked. These symptoms are often a result of living with parents or guardians that smoke in the home or in the car or if they smoked while in the room. There is also an increased risk in children for developing asthma, ear infections, and colds. Infants of smokers are often more prone to sudden infant death syndrome ([[www.sids.org/|SIDS]]). Adolescents are often affected by peers that smoke in their presence; it happens all the time because not all people smoke and it is a social gathering activity to talk and smoke. Second-hand smoke can cause withdrawal symptoms in children that can be expressed as depression, irritability, problems sleeping, increased appetite, and anxiety. Nicotine dependence in children can often be seen to impair concentration and results in poor school performance. They may also experience cravings for nicotine and increased temptation to smoke when they are around others that smoke.Children that have parents that smoke are more likely to engage in the act than those who have parents that are non-smokers. It has been estimated that around 20% of teen smokers exhibit substantial nicotine dependence. Recent research suggests that some adolescents may begin to experience a loss of control over their smoking within weeks of smoking the first cigarette. In both adults and children, using any amount of tobacco can quickly lead to nicotene dependence.
  • Adults, as well as children, that are exposed to nicotine may experience both short-term and long-term effects. Short-term effects include an increase in heart rate, blood pressure, and metabolism. The “fight-or-flight” response may also be experienced as a result of increased adrenaline production that causes rapid heartbeat, increased blood pressure, and rapid, shallow breathing. It takes an average of seven seconds for the effects of nicotine to reach the brain. Research indicates that there may be a drop in skin temperature, decreased appetite, diarrhea, and saliva excretion. The physical appearance of a smoker may also be altered. Smoking can change the structure of the skin, causing premature aging and wrinkles, as well as causing yellowing of teeth, fingers, and fingernails. Long-term effects include re-occurring problems with blood pressure, coronary heart disease, emphysema, shortness of breath, reduced fertility, and abnormal sperm forms. Individuals with HIV or other immuno-deficiency diseases are more apt to contract life-threatening illnesses due to the effects of a weakened immune system that are caused by nicotine. In addition, the nicotine in tobacco can damage cell structure, causing increased cell proliferation, which may cause several types of carcinomas. Nicotine has also been known to block the release of insulin into the blood stream, leading to hyperglycemia.The blockage of insulin also increases the smoker’s risk of developing type 2 diabetes and, those who already have diabetes, are at an increased risk for complications including kidney disease. Nicotine can also cause complications in pregnancy such as miscarriage, preterm delivery, and SIDS as well as low birth-weight in newborns. Newborns with low birth-weight are more likely to die or have learning or physical problems.
  • Gender and cultural differences in presentation
  • Many of the cultural and gender differences can be seen in the history of nicotine itself. Mayan cultures indicated use of tobacco in their stone carvings as far back as 900 A.D. The Native American cultures used tobacco ceremonially and the men of the tribe would often use it as a sign of wealth and friendship. Tobacco was brought to Europe in the 1500’s where it became popular via pipes, cigars, and snuff. Tobacco, however, was often punishable in some European and Asian cultures by mutilation and/or death. In the United States, tobacco still maintains its popularity and its respectability as a valuable cash crop.
  • Historically, more men than women use nicotine, especially in the form of chewing tobacco. It is often used to fit in socially and to project a certain image while at the same time give sensory rewards and emotional relief to the individual using it. Smoking, at one time, projected the appearance of wealth and prestige in Rome and France where it was socially acceptable for women to smoke as well. In the United States, smoking has begun to take on a negative connotation. New laws forbidding the act of smoking in public places and in vehicles around children have emerged. In addition, pregnant women who smoke are looked down upon as it goes against the new social norms. In one city in Arizona, it is not only illegal to smoke in public places or in the presence of children, but it is also illegal to smoke in vehicles with the windows rolled down.
  • Besides the traditional cigarettes and smokeless tobacco, there are several other types cigarettes that must be considered. Bidis are handmade cigarettes composed of tobacco hand-wrapped in a dried tendu or temburni leaf and tied with a string. Bidis comes in many flavors, including chocolate, wild cherry, and cinnamon. These types of cigarettes are relatively cheap and have a harmless appearance; however, because the the wrappers have a low combustibility the user has to smoke more. This is a problem because bidis produces more carbon monoxide and tar than conventional cigarettes. Bidis are popular in South Asian countries such as India, Sri Lanka, Bangladesh, Pakistan, Afghanistan, Cambodia, and Nepal. In these countries, poverty, low education, scheduled castes, and scheduled tribes are found to be associated with higher prevalence of tobacco use. Clove cigarettes called Kreteks contain a mixture of Indonesian tobacco and shredded clove spice wrapped in either an ironed corn husk or a slip of paper. Many smokers who use Kreteks inhale the chemicals much deeper because of their anesthetizing effects.
  • Although 60-70% similar to conventional cigarettes, they produce twice as much tar, nicotine, and carbon monoxide. The active ingredient in cloves known as Eugenol is the anesthetic and it is known to contribute to the development of respiratory tract infections. These infections are due to the numbing effect the ingredient has on the back of the throat and trachea which hides the harshness of the cigarette. This numbing effect contributes greatly to an increase in nicotine dependence. This type of tobacco product is mainly used in Indonesia; however, internet sales have increased its popularity to all other parts of the world. Another type of tobacco product is known as a hookah, or its alternate name “hubble bubble”. A hookah is a long-necked water pipe in which the smoke passes through a long tube and through an urn of water that makes a bubbling noise. In India and Persia, the bulb used to hold the water is made of coconut shells although in many cases they are made of glass, porcelain, silver, or crystal embedded with gold and silver. There has been little research done to support the claim that hookah smoking delivers less harmful substances to the smoker than do conventional cigarettes; however, hookah smoke contains significant amounts of carbon monoxide and nicotine. Hookah smoking has gained popularity in not only India and Persi, but also many of the Arab countries, London, England, and Paris, France have caused a regained interest due to the proliferation of Hookah cafes.
  • Smokeless tobacco is used as a broad term that refers to more than thirty types of products. These products are used around the world but are most common in northern Africa, Southeast Asia, and the Mediterranean region. These products are consumed without burning the product and can are used orally or nasally. Most of these products are placed in the mouth, cheek, or lip and are sucked (dipped) or chewed. Fine tobacco powder may be inhaled and absorbed through the nasal passages. Southeast Asia is a major producer and exporter of smokeless tobacco. In countries such as India and Bangladesh, smokeless tobacco is often associated with areas of low education and low income. Despite the harmful effects, smokeless tobacoo may be used to treat toothaches, headaches, and stomachaches. Harmful effects include an increase in the risk of oral cancers, oral submucous fibrosis, hypertension, and reproductive health problems.
  • In some cultures, such as First Nations People, tobacco is used as a medicine in ceremonial practices. For the purposes of honoring and including cultural traditions and healing practices in relation to new laws being written regarding the use of tobacco, the difference between tobacco use and dependence, ceremonial tobacco, and recreational use must be clearly defined.
  • The 1998 Surgeon General’s report, Tobacco Use Among U.S. Racial/Ethnic Minority Groups, addressed diverse tobacco-control needs of the four primary U.S. racial/ethnic minority populations: non-Hispanic blacks, American Indians/Alaska Natives (AI/ANs), Asians/Pacific Islanders, and Hispanics. The report results indicated that the prevalence of cigarette smoking among adults age 18 and older ranged from 40.4% for AI/ANs to 12.3% for the Chinese population. The prevalence amoung youths aged 12-17 years ranged from 27.9% for AI/ANs to 5.2% for the Japanese population.

Epidemiology

  • It has been found that 55%-90% of those that are diagnosed with mental disorders also use nicotine on a regular basis. In the general population, 30% of individuals were found to be users of tobacco that were absent mental illness. It has also been indicated that 25% of the population of the United States has been diagnosed with nicotine dependence. Of those that use tobacco on a regular basis, 45% can stop using nicotine eventually; however, it has been estimated that only 5% will be successful without help. People who have depression, schizophrenia, and other forms of mental illness are more likely to be smokers simply because it may be a form of self-medication for these disorders. People who abuse alcohol and illicit drugs are also more likely to be smokers. Diagnosis of substance dependence, including nicotine dependence as well as others, is based upon the ‘Four Cs’ Test. This test is conducted by psychiatrists, psychotherapists, social workers, and addiction counselors. This test focuses on four areas: compulsion, control, cutting down, and consequences. Compulsion is the intensity with which the desire to use a chemical, such as tobacco, overwhelms the patient’s thoughts, feelings, and judgements. Control focuses on the degree to which patients can (or cannot) control their chemical use once they have started using. Cutting down refers to the analysis of the withdrawal symptoms experienced by an individual. This aspect focuses on the effects of reducing chemical intake. The final factor deals with the consequences associated with the chemical dependence. This area deals with the denial or acceptance of the damage caused by the chemical. The ‘Four Cs’ Test is the DSM-IV based diagnosis of nicotine dependence.
  • Etiology
  • Nicotine dependence is caused by the reliance of receptors in the brain that deal with mood-altering and physical effects on the body. The nicotine binds to nicotine receptors that then stimulate such neurotransmitters including dopamine. These neurotransmitters become dependent on the chemical in order to regulate normal body functioning. Nicotene is responsible for a host of health problems; however, the physical and mood-altering effects in the brain are temporarily pleasing. It is these effects that spur continued use of tobacco products and this is ultimately what leads to dependence. Adolescents that smoke may be more prone to being diagnosed with nicotine dependency because their brains are not fully developed. The genes that are inherited play a role in some aspects of nicotine dependence. This is based on more than just the immediate environment (i.e. having parents that smoke). For example, the likelihood that an individual will start smoking and keep smoking may be partly inherited. Some people experiment with smoking and don’t experience the pleasure, so they never become smokers. Other people develop dependence very quickly such as the dependence seen in adolescents. Some “social smokers” can smoke just once in a while, and yet another group of smokers can stop smoking with no withdrawal symptoms. These differences can be explained by genetic factors that influence how receptors on the surface of the brain’s nerve cells respond to nicotine.
  • Empirically supported treatments
  • Medications, which include nicotine replacement therapy, can be effective treatments for nicotine dependency. Nicotine replacement therapy includes products that include nicotine at lower doses, without the appearance of the over 3,000 chemicals that are in tobacco products. These products include nicotine patches, gums, and lozenges. Prescription products, such as nicotine nasal spray (Nicotrol NS) and nicotine inhalers are also available on the market to help combat nicotine dependence. Many medications used to help curb the cravings of nicotine dependency do not include nicotine. Certain antidepressants, such as Zyban or Wellbutrin, can help increase the levels of norepinephrine and dopamine in the brain to reduce the need for nicotine. Varenicline, which targets nicotine receptors in the brain, and high blood pressure medication such as Clonidine are examples of other non-nicotine medications that are in use to help individuals reduce and/or stop the use of nicotine. Research shows that amalgamating medications and behavioral counseling is an effective way for long-term success in being sober from tobacco. The counseling helps develop the skills needed to stay away from the substance. In addition, the development of vaccines are being investigated which will prevent nicotine users from relapse. There are no physical tests top determine the exact degree to which an individual is dependent upon nicotine. A physician may assess the degree of an individual’s dependence by asking questions or having a questionnaire completed. The more cigarettes a person smokes each day and the earlier in the day a person smokes after awakening, the more dependent the individual is.
  • Most of the nicotine replacement products are available over-the-counter. The nicotine patch, which includes NicoDerm CQand Habitrol, delivers nicotine through the skin and directly into the bloodstream. A new patch is placed on the skin each day and the treatment period usually lasts for eight weeks or longer. The patch dosage may be adjusted or an additional medication may be needed in order to stop smoking if this has not occurred after two weeks. Nicotrol inhaler is a nicotine inhaler that is shaped like a cigarette. This allows the smoker to satisfy the urge as well as the physical act of smoking. This inhaler delivers nicotine vapors into the mouth where it is absorbed in the lining of the mouth directly into the bloodstream. However, the inhaler may cause side effects such as mouth and/or throat irritation and occasional coughing.
  • Current funding is being used to create opportunities for development and implementation of youth tobacco-control programs. Research shows that combining medicine with behavioral counseling provides the best chance for long-term success in abstaining from alcohol. Medication is used to lessen the withdrawal symptoms in an individual that has nicotine dependence while the behavioral treatments focus on helping the individual develop the skills needed to stay away from tobacco over the long run.
  • LINKS:

11. Alcohol Dependence (303.90)

  • DSM-IV-TR criteria·
  • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
  • (1) 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
  • (2) Withdrawal, as manifested by either of the following:
  • (a) The characteristic withdrawal syndrome for the substance (refer to criteria A and B of the criteria sets for Withdrawal from the specific substances)
  • (b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  • (3) The substance is often taken in larger amounts or over a longer period than was intended
  • (4) There is a persistent desire or unsuccessful efforts to cut down or control substance use
  • (5) A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
  • (6) Important social, occupational, or recreational activities are given up or reduced because of substance use
  • (7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
  • Specify if:
  • With Physiological Dependence
  • Without Physiological Dependence
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • In a Controlled Environment
  • Associated features
  • Statistics show that: in the United States about one out of ten people are alcohol dependent; there is either an intoxicated driver or pedestrian involved in approximately one half of all highway fatalities; and among individuals with alcohol dependence, approximately ten percent commit suicide (this is shown to be related to Substance Induced Mood Disorders) . Other studies show a connection between long term heavy alcohol use and the development of Dementia and Wernicke’s disease. In pregnant women alcohol dependence can also cause different birth defects such as Fetal Alcohol Effects (FAE) and Fetal Alcohol Syndrome (FAS).Fetal Alcohol Syndrome is more severe and usually causes some form of mild Mental Retardation and physical defects leading to intellectual deficiencies and learning disabilities. The statistics concerning FAS are staggering. It is estimated that out of every 1000 infants born alive, approximately 1.5 has FAS. Not only is Fetal Alcohol Syndrome the primary preventable cause of Mental Retardation in the United States, it is also the third leading cause of birth defects.
  • Regarding tolerance, it is a sign that the liver has been damaged when reverse tolerance, that is, the need of less alcohol to produce the desired effect, appears.
  • Child vs. Adult presentation
  • Having hyperactive ADHD increases teenagers’ chances of using alcohol. Children who come from families that sanction drinking have a higher risk of becoming alcohol users. Adolescents and teenagers who first use alcohol are starting the experimentation process. Adults who first use alcohol are doing so because of some positive or negative influence in their lives.
  • Gender and Cultural differences in presentation
  • Religion is a large factor in the rates of alcohol abuse and dependence in different cultures. Part of that influence is the context in which the alcohol is being used. There tends to be lower rates of Alcohol Dependence in cultures that use alcohol in religious ceremonies. Rates of Alcohol Dependence are higher in cultures where religion uses alcohol as a social lubricant.
  • Alcohol dependence is more prominent among Native Americans and Irish or Irish Americans. For Native Americans this stems from the history of being deprived of their lands and denied the stability of economic success. Because their homes are usually too small and crowded to get together with friends and family, the pub is usually the social center of the Irish way of life.
  • Men represent a larger population of alcohol dependent’s than do women. Numerous studies have shown that men will be less likely to abstain from using alcohol, and hence more often become dependent on the substance. Men generally consume more alcohol and abuse alcohol more frequently than women (Homila 2004). From culture to culture the size of this discrepancy varies, and more research is needed to explain why these cultural differences exist.
  • Epidemiology
  • Ninety percent of the population has used alcohol at some point in their lives. Alcohol has the effects of positive reinforcement by changing brain and body chemistry. Alcohol also has a negative reinforcement effect of removing inhibitions and anxiety. It is at least three times as likely for a primary biological relative to have Alcohol Dependence if a first degree biological relative has the same disorder. The environment of where individuals live and their Socio Economic Status also play a role in developing Alcohol Dependence. There is also a new theory being studied that connects Alcohol Dependence to abnormally low serotonin levels.
  • Etiology
  • There are many various factors that influence whether or not an individual develops alcohol dependence. From a psychoanalyst perspective, Alcohol Dependence would be seen as a result of anxiety, repressed emotions, or neurotic conflict, and could also be used as a way to boost self esteem. Having an oral fixation has also been connected to Alcohol Dependence. There can also be a genetic connection. A key factor is that the individual must hold a positive attitude towards alcohol. Peer pressure during adolescence and the media portrayal of alcohol (having sex appeal) throughout life are also strong influential factors. Once an individual gives into the pressure he will start to experiment with alcohol. These experiments may have positive or negative effects. If the individual has a positive opinion about alcohol and enjoys drinking then he will continue to drink. If he steadily increases the amount of alcohol he drinks it could eventually lead to complications of his everyday life. Ads for alcoholic beverages are increasigly targeted at the youth, especially young men, sending the message that drinking beer may, for example, cause scandalously clad women to flock to one’s location. The individual then begins to experiment with alcohol, usually with a peer group, and continues use through school. Problems occur and worsen the heavier the alcohol use becomes.
  • Two key etiological factors are generally agreed upon. First, the individual must have a positive attitude toward alcohol.
  • Empirically supported treatments
  • It is much easier to treat and stop the alcohol abuse before it becomes dependence. There are many proposed treatments for an individual with Alcohol Dependence. Psychotherapy, ketamine-enhanced psychotherapy (Kolp, Friedman, Young & Krupitsky, 2006), medications such as Disulfiram (Mustard, May & Phillips,2006; Obholzer, 1974), 12-step programs (Gomes & Hart, 2009), and religious programs are all empirically supported treatments for individuals with Alcohol Dependence. It is not uncommon for two or more of these methods to be used in treating individuals with Alcohol Dependence. Spirituality is suggested to be inversely related to alcohol use, therefore, increasing one’s spirituality is an approach taken by many substance-abuse professionals in an attempt at treatment of the Substance-Related Disorders (Johnson, Sheets & Kristeller, 2008). Twelve-step programs such as Alcoholics Anonymous or Narcotics Anonymous are examples of commonly used spirituality-based treatments for Substance-Related Disorders. It is suggested that use of a 12-step program in combination with psychotherapy is quite effective (Knack, 2009). Groh, Jason, Ferarri, & Davis (2009) examined the effectiveness of 12-step involvement in combination with the use of an Oxford House (group recovery living) in 150 substance-dependent individuals. Groh (2009) and his colleagues found that in the 12-step/Oxford house combination condition, 87.5% of individuals with “high 12-step involvement” were abstinent at 24 months. Abstinence rates at 24 months for individuals with “low 12-step involvement” were fairly similar across both conditions; 12-step/Oxford combination = 31.4%, 12-step alone = 21.2% (Groh, Jason, Ferarri, & Davis, 2009)
  • The Disease Model sees Alcohol dependence as a medical condition. This model ties into the genetic factor. If Alcohol Dependence is seen as a biological condition then the only successful way to treat it, is to completely abstain from drinking alcohol. The self help group Alcoholics Anonymous (AA) recognizes the disease model. It is unsafe for an individual that is dependent on alcohol to stop “cold turkey”. The alcohol must be removed from the system in a slow process of detoxification. To prevent sever withdrawal complications, the individual will be given some form of anti-anxiety medications. Medications such as Antabuse may also be used in an attempt to maintain abstinence. Severe Alcohol Dependence can have a spontaneous remission with about twenty percent never experience drinking problems again.
  • LINKS:

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12. Alcohol abuse (305.00)

  • DSM-IV-TR criteria
  • A) A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
  • (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  • (2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  • (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
  • (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication physical fights)
  • B) The systems have never met the criteria for Substance Dependence for this class of substance.
  • Associated features
  • Alcohol abuse has a high co-morbidity rate with the abuse of other substances. When substances that are normally abused are not available, alcohol may be used as an alternative. Alcohol abuse can also be associated with other psychological disorders such as conduct disorder and antisocial behavior in adolescents. Alcohol has the psychological effect of inhibition reduction making it seem as if it is a stimulant. Alcohol is in fact a depressant of the central nervous system (CNS). It is estimated that forty percent of all people in the United States will be involved in an accident related to alcohol at some point during their lives and that fifty five percent of all fatal driving accidents are in some way due to alcohol. A diagnosis of Alcohol Abuse can be applied when alcohol is causing problems in the individual’s life activities. Binge drinking is a serious problem and also a form of abuse that occurs in about fifty-percent of college men. The average age that one peaks at consumption and abuse is twenty one. Individuals who qualify for Alcohol Abuse typically consume alcohol in situations that are hazardous to one’s health. The most common of which is driving while intoxicated (DWI) from alcohol and is the number one cause of all automobile accidents in the United States.
  • Alcohol withdrawal occurs when one stops or reduces heavy or prolonged use. Some withdrawal symptoms are autonomic hyperactivity, increased hand tremor, psycho-motor agitation, insomnia, nausea or vomiting, and transient visual, auditory or tactile hallucinations or delusions. Also anxiety and grand Mal seizures may be present.
  • Child vs. adult presentation
  • According to recent studies, the prevalence of alcohol abuse among adolescents ranges between four and percent in males. This percentage has been found to increase with age. Children who start to use alcohol at an earlier age (before fifteen) have a higher tendency to abuse alcohol later on. The age at which adults abuse alcohol varies widely. Males tend to present with alcohol abuse at a younger age than females.
  • Gender and cultural differences in presentation
  • Men are diagnosed with alcohol abuse more often than women. The ratio has been as high as 5:1 with a variance between age groups. Men start drinking at a younger age than women, however, once alcohol use becomes abusive, the disorder progresses faster in females than in males. The rate is highest among men aged 18 to 25, most of which are in college. Throughout different cultures, the amount of alcohol abuse varies widely. There are many possible reasons for this variance; alcohol is more readily available in some cultures than in others and each culture has its own social beliefs and regulations about drinking. What is socially acceptable in one culture is not necessarily the same in others. Cultural attitudes about alcohol consumption are also affected by the religious beliefs of each culture. Alcohol abuse also has different physiological effects on people of different cultures because of the religious beliefs and what is expected when alcohol is consumed, such as hallucinations or delusions as a possibility.
  • Prevalence is high in western countries; Asian cultures have a low prevalence but male to female ratio is high. Caucasian males generally reach a peak, in terms of alcohol use, during early adulthood from ages 18-30. After age 30 alcohol use in this group tends to wane throughout the rest of life. African American males often display drinking patterns completely different from those of Caucasion males. African American males generally have low instances of alcohol abuse during their 20’s, and rising use during their 30’s and 40’s (Homila, 2004).
  • Women are affected differently than men. When consuming alcohol women become more impaired even when taking weight into account. The reason is that alcohol mixes with the water in your body and that dilutes it. Men generally have more water in their bodies than women, so alcohol is diluted more when men drink it versus women. A binge drinker is classified as a person that consumes 5 or more drinks in a one week period more than once a week in men, and only 4 or so for women in the same classification.
  • Epidemiology
  • It is estimated that between sixty-six and ninety percent of all adults have at some time in their lives consumed alcohol. Although alcohol abuse is not as severe as alcohol dependence, it is more common and can be seen a precursor to dependence. Alcohol is the second most used psychoactive substance, next to caffeine. Lifetime prevalence is 13.3% to 15% in the general population. The highest prevalence is in ages 26-34 with 77% prevalence. Alcohol abuse and dependence are co-morbid with Axis I and II, mood disorders, anxiety, Schizophrenia and Anti-Social Personality disorder. Depression may result from effects of intoxication or withdrawal. Concurrent and sequential treatments are questionable for other problems.
  • Etiology
  • Individuals who have a positive attitude about alcohol consumption tend to be more likely to abuse alcohol. There are many different types of and reasons for alcohol abuse. These reasons range from psychosocial to physiological and cultural. One type of alcohol abuse is getting drunk or binge drinking (which has a high prevalence in college men) at social events. Alcohol abuse can also be attributed to other substance abuse disorders and psychological disorders. Alcohol abuse can be used to deal with physiological problems or pain. There is also a possible genetic factor involved in alcohol abuse and dependence.
  • Empirically supported treatments
  • The first and most important step in treatment of alcohol abuse is to make the individual realize and admit that he abuses alcohol. The most effective way to prevent alcohol abuse is abstaining from its use. Clinical therapy can also be used to help the person learn to control the amount of alcohol consumption. Prescription medications can also be used to reduce the desire to consume alcohol. Alcoholics Anonymous is a self-help group that has been around for over seventy years. This program is structured around alcohol dependence but can be used by alcohol abusers that realize they may be on the road to dependence. Its method is called the “Twelve Step Program.” Members introduce themselves anonymously and progress through the twelve steps. Some studies show a greater recovery in those individuals who participate in non-emotion centered therapy. Other individuals involved in therapy centered on depression or other emotional problems have a tendancy to show lower recovery rates (Raitasalo, 2005).
  • Links

13. Alcohol Intoxication (303.00)

  • DSM-IV-TR criteria
  • A. Recent ingestion of alcohol
  • B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, alcohol ingestion.
  • C. One (or more) of the following signs, developing during, or shortly after, alcohol use:
  • (1) Slurred speech
  • (2) Incoordination
  • (3) Unsteady gait
  • (4) Nystagmus (involuntary eye movement)
  • (5) Impairment in attention or memory
  • (6) Stupor or coma
  • D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

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14. Alcohol Withdrawal(291.81)

  • DSM-IV-TR criteria
  • A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
  • B. Two (or more) of the following, developing within several hours to a few days after Criterion A:
  • (1) Automatic hyperactivity (e.g., sweating or pulse rate greater than 100)
  • (2) Increased hand tremor
  • (3) Insomnia
  • (4) Nausea or vomiting
  • (5) Transient visual, tactile, or auditory hallucinations or illusions
  • (6) Psychomotor agitation
  • (7) Anxiety
  • (8) Grand mal seizures
  • C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
  • Specify if:
  • With Perceptual Disturbances
  • Emperically supported treatment
  • Many treatment with alcohol withdrawal syndroms can be managed with various pharmaceutical medications including barbituates, benzodiazepines, and clonidine, certain vitamins are also an important part of the management of alcohol withdrawal syndrome.
  • Barbituates are superiors to diazepam in the treatment of severe alcohol withdrawal syndromes such as delirium tremens but equally effective in mildr cases of alcohol withdrawal.
  • Clonidine has demonstrated superior clinical effects in the suppression of alcohol withdrawal symtpoms in a head to head comparison study with the benzodiazepine drug.
  • Benzodiazepines are the most commonly used drug for the treatment of alcohol withdrawal and are generally safe and effective in suppressing alcohol withdrawal signs. Chlordiazepoxide and diazepam are the benzodiazepines most commonly used in alcohol detoxification. Benzodiazepines can be life saving, particularly if delerium tremens appears during alcohol withdrawal. Benzodiazepines should only be used short term in alcoholics who aren’t already dependent on benzodiazepines as benzodiazepines share cross tolerance with ethanol and there is a risk of replacing the addiction with a benzodiazepine dependence or worse still adding an additional addiction. Furthermore disrupted GABA benzodiazepine receptor function is part of alcohol dependence and chronic benzodiazepines may prevent full recovery from alcohol induced mental effects. Benzodiazepines have the problem of increasing cravings for alcohol in problem alcohol consumers and they also increase the volume of alcohol consumed by problem drinkers. The combination of benzodiazepines and alcohol can amplify the adverse psychological effects of each other causing enhanced depressive effects on mood and increase suicidal actions and are generally contraindicated except for alcohol withdrawal.
  • Vitamins
  • Alcoholics are often deficient in various nutrients which can cause severe complications during alcohol withdrawal such as the development of wernicke syndrome. The vitamins of most importance in alcohol withdrawal are thiamine and folic acid. To help to prevent wernicke syndrome alcoholics should be administered a multivitamin preparation with sufficient quantities of thiamine and folic acid. Vitamins should always be administered before any glucose is administered otherwise wernicke syndrome can be precipitaed.
  • Links
  • DSM-V Proposed Changes: adding “Alcohol-Use Disorder”
  • DSM-V Alcohol-Use Disorder Criteria:

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:

  1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  4. tolerance, as defined by either of the following:
  1. a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect
  2. b. markedly diminished effect with continued use of the same amount of the substance
  3. (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
  1. withdrawal, as manifested by either of the following:
  1. a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
  1. b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  2. (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
  1. the substance is often taken in larger amounts or over a longer period than was intended
  2. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  4. important social, occupational, or recreational activities are given up or reduced because of substance use
  5. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  6. Craving or a strong desire or urge to use a specific substance.
  1. Severity specifiers:
  1. Moderate: 2-3 criteria positive
  2. Severe: 4 or more criteria positive
  3. Specify if:
  4. With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
  5. Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)
  6. Course specifiers (see text for definitions):
  7. Early Full Remission
  8. Early Partial Remission
  9. Sustained Full Remission
  10. Sustained Partial Remission
  11. On Agonist Therapy
  12. In a Controlled Environment

  1. 15. Cocaine Abuse and Dependence (305.6)

  1. DSM-IV-TR criteria
  1. A. A maladaptive pattern of cocaine use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12 month period
  1. 1. Recurrent cocaine use resulting in a failure to fulfill major role obligations at work, school or home.
  2. 2. Recurrent cocaine use in situations in which it is physically hazardous
  3. 3. Recurrent cocaine-related legal problems
  4. 4. Continued cocaine use despite having a persistent or recurrent social or interpersonal problem caused or exacerbated by it use.
  1. B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
  1. Associated features
  1. Intoxication of cocaine is accompanied with a number of symptoms. There is heightened alertness and euphoria associated with intoxication of cocaine. Behavioral changes such as hyperactivity, restlessness, impaired judgment and functioning, and anxiety are also associated with intoxication. People under a more severe intoxication will experience more agitation, confusion, and possibly seizures.
  2. Withdrawal symptoms can include a dysphoric or unpleasant mood, fatigue, unpleasant dreams, insomnia, psycho motor retardation, and increased appetite. When people are in this dysphoric mood, they think back to the euphoria they received from the cocaine high, which in turn increases their cravings to use cocaine again, to get out of the mood.
  3. Cocaine abusers experience a number of symptoms that affect every part of the body. First of all, cocaine affects the nervous system, which causes euphoria. It can also cause symptoms like hallucinations and muscle jerks. Cocaine also affects the brain, which makes it so addictive. Since cocaine is mostly sniffed or snorted through the nose, this causes serious effects on the sinuses and nose. Smoking cocaine can affect the lungs, much the way smoking cigarettes affect the lungs and breathing. Cocaine also has an effect on the heart. One of the main effects of cocaine is stimulating the sympathetic nervous system which is directly related to the heart and the “flight-or-fight” response. Cocaine abuse can cause increased heart rate, blood pressure, and decreasing the size of the blood vessels, which in turn restrict blood flow to the heart.
  4. People dependent to cocaine will do nearly anything to get cocaine. This can interfere with their job, schooling, and relationships. People dependent on cocaine have many of the same symptoms of intoxication. They have increased energy, weight loss, and not involved in normal activities, along with many other symptoms.
  1. Child vs. adult presentation
  1. There has not been much research done in the area of child vs. adult presentation. Children, however, can be affected by cocaine use in their parents. A fetus can be harmed when a mother is using cocaine while pregnant resulting in the baby having withdrawal symptoms when born. Women who are pregnant and using cocaine experience more miscarriages. Cocaine can affect the development of the fetus. Cocaine can cause certain areas of the brain to develop abnormally. It can cause problems later on in life with being able to pay attention, processing information and staying focused, compared with those who are not exposed to the drug. Newborns born to mothers who used cocaine during the pregnancy have lower birth weight, smaller head circumference, and are shorter than those babies who were born to mothers not using cocaine. These effects have a great impact on the child throughout their life. Children can also be affected by the second-hand smoke from parents who smoke cocaine. Overall, there is no research showing that children use cocaine. Mothers who use cocaine can affect the development of their children. Cocaine use generally begins in adolescence and the symptoms are the same as those experienced by adults using cocaine.
  1. Gender and cultural differences in presentation
  1. There are not many differences in the presentation of intoxication or withdrawal symptoms across genders; however it has been found that women typically use cocaine for different reasons. It is usually a response to stress, hoping that the drug will make them feel better. In men, it has been found that they use cocaine to feel even better when already feeling good. More specifically, a study conducted in 2002, found that estrogen may have a role in sex-based addictions. The study found that women usually become dependent after using cocaine for shorter amounts of time as compared with men. Estrogen can affect the immediate response to cocaine as well as the long-term effects of the drug. Another study, published in 2005, tested women and men stress reactivity. These participants were dependent on cocaine. They were all given a psychological stress task, the Mental Arithmetic Task, and a Cold Pressor Task. The participants were measured on their physiological stress response (heart rate, etc.), their subjective stress responses (nervousness, etc.), and their cocaine cravings they experienced. The results showed that women demonstrated more subjective reactivity. They had higher ratings of nervousness, stress, and pain compared with the men in the study. The study showed that women seem to be more stressed overall when dependent on cocaine as compared to men. However, this was the first study that used the testing procedure that was used and none have been done since.
  2. Culturally there has been no research in the area of difference of presentation. The main differences that have been researched are differences in uses among different ethnic groups.
  1. Epidemiology
  1. In 2007, the National Survey on Drug Use and Healthreported that 35.9 million Americans have used cocaine at least once in their life. In 2007, students who took the Youth Risk Behavior Surveillance System, 7.2% reported trying cocaine at least once. While only 3.3% reported having used cocaine in the past month. Nearly half of federal and state prisoners have tried cocaine once in their life. Research shows that nearly 75% of people that try cocaine will become addicted. Only 25% of people that are using cocaine will be able to stop without any help at all. Throughout the 1990’s to present-day, cocaine use has remained stable, with no significant increases or declines. The number of people trying cocaine has gone down since the 1980’s, however it has not been that significant. Adolescents show high rates of cocaine usage. Hispanic adolescents show the highest rates of cocaine use in the 30 days prior to taking the Youth Risk Behavior Survey. Caucasian adolescents report the next highest rate, then African American adolescents. Newer research has shown that drug use in adolescents has gone down since 2001. However, Hispanic adolescent drug use is still an area of concern. Currently, Hispanic adolescents are using cocaine more than Caucasian and African American adolescents. Additionally, research has shown that cocaine use is rising in European countries. One group of researchers believes that to combat this, a public health approach is necessary.
  1. Etiology
  1. Research has shown that repeated exposure to cocaine can cause a change in genes and this leads to an altered level of a protein that regulates dopamine levels. Dopamine is associated with the euphoria received from cocaine use. This causes many people to become addicted or dependent on cocaine. Cocaine is addictive and changes genes, making it hard to stop the addiction. It has also been found that if one has a family member using cocaine, they are more likely to do the same. While the nature of the drug is addictive, one’s environment can also have an effect on using cocaine.
  1. Empirically supported treatments
  1. While there is no cure for cocaine abuse or dependence, there are therapies and drugs that can help people be relieved of the symptoms of intoxication or help them make a life change to get off of the drug all together. However, there are no guarantees. First, psychosocial treatments provide support for behavioral change. About half of users in this setting can abstain from cocaine for about a month to a month and a half. However, the success of the program depends on the duration of the program and the specific designs of the program. Many use a 12-step approach to changing their behavior. This is based on getting help with being drug-free from a higher being. Another type of therapy is Relapse Prevention. This helps people understand their body and the cues they get so they can manage their use and relapse symptoms. Another psychosocial treatment is a Matrix Neurobehavioral Model Treatment. This involves many types of therapies including individual therapy, family education, and relapse prevention groups. This is also a 12-step program that can include meetings with mandatory urine tests to see if members are actually improving. Next, much research has been done regarding pharmacological treatments. However, while some initially have shown success, most have failed to show similar results when tested again. Drugs can be helpful for cocaine intoxication, though. Benzodiapines have shown to help people with intoxication symptoms that do not go away. Benzodiapines are also helpful to treat the withdrawal symptoms. Roughly 20 drugs have been tested in helping with cocaine dependence. There is no current evidence for any effective pharmacological treatment for cocaine dependence. Psychosocial treatment proves to be the most effective treatment, currently. In 2005, a group of researchers developed a system, called Cocaine Rapid Efficacy Screening Trial (CREST) which is a randomized method for testing and comparing the effect of pharmacological treatments on cocaine dependence. The CREST started out with a 2-4-week period of gathering information, then the 8-week treatment period. The participants were given urine tests, cocaine craving ratings, mood test, along with a few other tests and measures to track the progress of their treatment and the drug. This study was done in 4 major United States cities and 19 total drugs were tested for their effectiveness in treating cocaine dependence. Their findings showed three drugs (reserpine, cabergoline, and, tiagabine) that showed signs of effectiveness. These drugs were to be tested in a full-scale research experiment. No pharmacological treatments have been found to help people dependent on cocaine. They only help treat physical symptom associated with cocaine use. The only supported treatment is psychosocial therapy.
  1. Links
  1. Cocaine, Marijuana, Crack, Meth, Heroin Changes Brain ChemistryDrugs Damaging the Brain
  1. DSM-V Proposed Changes: adding “Cocaine-Use Disorder”
  2. DSM-V Cocaine-Use Disorder Criteria:
  3. A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
  4. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  5. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  6. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  7. tolerance, as defined by either of the following:
  1. a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect
  2. b. markedly diminished effect with continued use of the same amount of the substance
  3. (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
  1. withdrawal, as manifested by either of the following:
  1. a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
  2. b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  3. (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
  1. the substance is often taken in larger amounts or over a longer period than was intended
  2. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  4. important social, occupational, or recreational activities are given up or reduced because of substance use
  5. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
  6. Craving or a strong desire or urge to use a specific substance.
  1. Severity specifiers:
  2. Moderate: 2-3 criteria positive
  3. Severe: 4 or more criteria positive
  4. Specify if:
  5. With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
  6. Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)
  7. Course specifiers (see text for definitions):
  8. Early Full Remission
  9. Early Partial Remission
  10. Sustained Full Remission
  11. Sustained Partial Remission
  12. On Agonist Therapy
  13. In a Controlled Environment
  14. BACK TO TOP

  • 16. Cannabis Abuse and Dependence (305.20/304.3)

  • DSM-IV-TR criteria
  • A. Cannabis is a generic term used to denote the several psychoactive preparations of the plant Cannabis sativa. The major psychoactive constituent in cannabis is ∆-9 tetrahydrocannabinol (THC). Cannabis impairs cognitive development (capabilities of learning), including associative processes; free recall of previously learned items is often impaired when cannabis is used both during learning and recall periods
  • B. Cannabis impairs psycho-motor performance in a wide variety of tasks, such as motor coordination, divided attention, and operative tasks of many types; human performance on complex machinery can be impaired for as long as 24 hours after smoking as little as 20 mg of THC in cannabis; there is an increased risk of motor vehicle accidents among persons who drive when intoxicated by cannabis.
  • C. Some difficulties when cannabis is used may interfere with academic or occupational achievement or with social communication. Coding should be in AXIS I: CLINICAL DISORDERS/OTHER DISORDERS THAT MAY BE A FOCUS OF CLINICAL ATTENTION Under Substance-related disorders.
  • Associated features
  • Cannabis used during pregnancy is associated with impairment in fetal development leading to a reduction in birth weight; it also may lead to postnatal risk of rare forms of cancer although more research is needed in this area. Marijuana is the most used illicit drug in the United States. According to the 1994 National Household Survey on Drug Abuse, averages of 10 million Americans use marijuana each month. Within a few minutes of inhaling marijuana smoke, users likely experience dry mouth, rapid heartbeat, some loss of coordination and poor sense of balance, and slower reaction times, along with intoxication. Blood vessels in the eye expand. For some people, marijuana raises blood pressure slightly and can double the normal heart rate. This effect can be greater when other drugs are mixed with marijuana.
  • Cannabis has been proven to cause damage with short term memory. This is caused by the THCs effect on the hippocampus, the area of the brain responsible for memory formation
  • Cannabis smoke contains 50 – 70 percent more carcinogenic hydrocarbons than tobacco smoke. This has been suspected to be more likely to cause lung cancer. People inhaling the smoke also tend to hold the smoke in their lungs longer than cigarette smoke.THC has also been proven to inhibit a persons immune system, making them much more vulnerable to infectious diseases.
  • Child vs. adult presentation
  • NIDA’s 1995 Monitoring the Future study found that from 1991 to 1995, marijuana use in the 12 months before the surveys rose from 23.9 to 34.7 percent among the Nation’s 12th graders, from 16.5 to 28.7 percent among 10th graders, and from 6.2 to 15.8 percent among 8th graders. Children often present about the same effects as adults on the substance directly after inhalation (see associated features). Peer pressure is a factor for children if other delinquents their age are engaged in use or around somebody who is. It is continuously becoming more and more popular among a variety of ages. Adult use is very likely to have risen as well or just continued their use through high school and college because of their liking of the substance and the good times associated with it.
  • Gender and cultural differences in presentation
  • The Drug Abuse Warning Network (DAWN), a system for monitoring the health impact of drugs, estimated that, in 2001, marijuana was a contributing factor in more than 110,000 emergency department (ED) visits in the United States, with about 15 percent of the patients between the ages of 12 and 17, and almost two-thirds were male. On average, 53 percent of juvenile male and 38 percent of juvenile females arrested and tested positive for marijuana; males are more likely to be associated with such deviant behavior but females are not restricted from use; there is just a difference in amount use and the frequency of occurrence. Cultures in America are more likely to run across this cannabis substance because of the diversity and the many people in the United States.
  • Epidemiology
  • Cannabis is by far the most common and widely cultivated, trafficked, and abused illicit drug. Half of all drug seizures worldwide are related to cannabis. The geographical spread of those seizures is also global, covering practically every country of the world. About 147 million people, 2.5% of the world population, consume cannabis (annual prevalence) compared with 0.2% consuming cocaine and 0.2% consuming opiates.
  • Etiology
  • Cannabis is often blamed as the “gateway” drug but no evidence seems to be able to support this claim. There is a correlation between association of “having a good time” and reuse. If the user learns to associate enjoyment with the activity then he/she will be much more likely to use it again. People can build up a tolerance to cannabis so they tend to use and abuse more the longer they use the substance. Although the causes of use vary from person to person, some use it for “medicinal uses.” Cannabis, and the THC that is in it, is often used to treat nausea, pain, and even glaucoma. Also, it has been used in cancer patients to get them to eat. This is still, however, considered illegal in most states.
  • Empirically supported treatments
  • Treatment programs directed at marijuana abuse are rare, partly because many who use marijuana do so in combination with other drugs such as cocaine and alcohol. Therapy may be individual treatment that includes motivational interviewing and advice on ways to reduce marijuana use. By increasing patients’ awareness of what triggers their marijuana use, they may be able to better manage their addiction. Four of the most commonly used treatments are: Basic principles, Psychotherapy, Behavioral Therapy, and 12-step programs. Basic Principles treatment includes: education, urine tests, and communication. Psychotherapy focuses on the reasons why the patient is using, and often encorporates other users of the substance who are currently battling with the same issues. Behavioral Therapy teaches users of the substance to focus on other ways to reduce anxiety with special emphasis is on relaxation techniques, self-control skills, and assertiveness training. Twelve-Step programs, such as Narcotics Anonymous (NA), focus on building a support group that is battling with similiar issues, relying on a higher power to remove the obsession to use the substance, and helping others in their battle with the substance.
  • Links
  • DSM-V Proposed Changes: adding “Cannabis-Use Disorder” and “Cannabis Withdrawal”
  • DSM-V Cannabis-Use Disorder Criteria:
  • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
  • recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  • recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  • continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  • 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
  • (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
  • withdrawal, as manifested by either of the following:
  • a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
  • b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  • (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
  • the substance 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 substance use
  • a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  • important social, occupational, or recreational activities are given up or reduced because of substance use
  • the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  • Craving or a strong desire or urge to use a specific substance.
  • Severity specifiers:
  • Moderate: 2-3 criteria positive
  • Severe: 4 or more criteria positive
  • Specify if:
  • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
  • Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)
  • Course specifiers (see text for definitions):
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • On Agonist Therapy
  • In a Controlled Environment
  • DSM-V Cannabis Withdrawal Criteria:
  • A. Cessation of cannabis use that has been heavy and prolonged
  • B. 3 or more of the following develop within several days after Criterion A
  • 1. Irritability, anger or aggression
  • 2. Nervousness or anxiety
  • 3. Sleep difficulty (insomnia)
  • 4. Decreased appetite or weight loss
  • 5. Restlessness
  • 6. Depressed mood
  • 7. Physical symptoms causing significant discomfort: must report at least one of the following: stomach pain, shakiness/tremors, sweating, fever, chills, headache
  • C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • D. The symptoms are not due to a general medical condition and are not better accounted for by another disorder

  • 17. Phencyclidine Abuse and Dependence (305.9)

  • DSM-IV-TR criteria
  1. See above for specific abuse and dependence criteria.
  • Associated features
  1. Phencyclidine can be sold as a crystalline powder, paste, liquid, or a drug soaked paper. Common street drug names for Phencyclidine are: PCP, angel dust, boat, tic tac, zoom, hog, ozone, rocket fuel, wack, and shermans. It can be smoked, injected or snorted; smoking being the most common way it is used. It is sometimes used as an additive to marjuanna, and in this case the street names could include but are not limited to: super grass, lovelies, wet, fry, killer joints, and waters.
  2. Depending on the route in which the drug is used, as well as the dosage, the effects and severity of the effects will vary. It is often known as the “dissociative anesthetic” because of its distortment in sights and sounds. PCP can give an individual the feeling of detachment from his or her environment and self and have psychological and physiological effects such as: sedation, immobility, amnesia, numbness, slurred speech, rapid and involuntary eye movements, increased blood pressure, elevated tempature and heart rate, analgesia, and (with a high enough dosage) illusions and hallucinations.
  3. Chronic use of the drug can result in several impairments; speech, memory, and thinking. Long-term effects can include suicidal ideation, depression, anxiety, and social isolation. There have also been drowning deaths, violent and accidental deaths, and suicide linked to the usage of PCP.
  • Child vs. adult presentation
  1. PCP abuse occurs more in high school students and young adults, rather than in children. Studies have shown that the usage has varied among ages and has been seen prevalent in anywhere from 12 to 34; 26 to 34 being the highest range where users typically fall under. However, children may be exposed to it due to parental use and neglect.
  • Gender and cultural differences in presentation
  1. It is not very common but more PCP use is among males than females because of association with delinquent peers is most likely male involvement.
  • Epidemiology
  1. PCP is associated with 10% of substance abuse deaths and 32% of related emergency room visits. Most users are between 18-25 years of age, and account for more than 50% of cases. Most patients are more likely to be white males. Mostly used in the United States.
  2. Phencyclidine was once marketed as an anesthetic in United States for medical purposes under the trade names of Sernyl and Sernylan, but is no longer produced or used in the U.S. It was used on patients before surgery to calm them down, and used during and after surgery to ease pain, but after many reports of troubled speech, hallucinations, disoriented behavior, and other disturbing effects, it was withdrawn from the market in 1979.
  • Etiology
  1. Phencyclidine (PCP) is a hallucinogenic drug that can mimic several aspects of the schizophrenic symptomatology in healthy volunteers. In a series of studies PCP was administered to rats to determine whether it was possible to develop an animal model of the positive and negative symptoms of schizophrenia. The rats were tested in the social interaction test and it was found that PCP dose-dependently induces stereotyped behavior and social withdrawal, which may correspond to certain aspects of the positive and negative symptoms, respectively. The effects of PCP could be reduced selectively by anti-psychotic drug treatment, whereas drugs lacking anti-psychotic effects did not alleviate the PCP-induced behaviors. Together these findings indicate that PCP effects in the rat social interaction test may be a model of the positive and negative symptoms of schizophrenia with face and predictive validity and that it may be useful for the evaluation of novel anti-psychotic compounds.
  • Empirically supported treatments
  1. Hospitalization is recommended when acute PCP intoxication occurs because hyperpyrexia and other autonomic instabilities can lead to death; Benzodiazepines, like Lorazepam, are good for these patients and serve well for controlling agitation and seizures. Typical anti-psychotics, such as, Phenothiazines and haloperidol help to control psychotic symptoms. In order to help eliminate Phencyclidine dependence, ammonium chloride should be given to help extract it from the body. As far as psychological treatment goes, out-patient treatment or follow-ups, along with utilizing the communities resources are essential in staying clean from the drug. Life style changes, such as staying away from places, people, and things are encouraged. Psychotherapy is often beneficial to users as well as attending Narcotics Anonymous as a support program.
  • DSM-V Proposed Changes: adding “Phencyclidine-Use Disorder”
  • DSM-V Phencyclidine-Use Disorder Criteria:
  • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
  1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  4. 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
  • (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
  1. withdrawal, as manifested by either of the following:
  • a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
  • b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  • (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
  1. the substance is often taken in larger amounts or over a longer period than was intended
  2. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  4. important social, occupational, or recreational activities are given up or reduced because of substance use
  5. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  6. Craving or a strong desire or urge to use a specific substance.
  • Severity specifiers:
  • Moderate: 2-3 criteria positive
  • Severe: 4 or more criteria positive
  • Specify if:
  • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
  • Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)
  • Course specifiers (see text for definitions):
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • On Agonist Therapy
  • In a Controlled Environment

  • 18. Inhalant Abuse and Dependence (305.9)

  • DSM-IV-TR criteria
  1. INHALANT DEPENDENCE. The DSM-IV-TR specifies that three or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for inhalant dependence:
  • Tolerance. The individual either has to use increasingly higher amounts of the drug over time in order to achieve the same effect, or finds that the same amount of the drug has much less of an effect over time than before. After using inhalants regularly for a while, people may find that they need to use at least 50% more than the amount they started with in order to get the same effect.
  • Loss of control. The person either repeatedly uses a larger quantity of inhalant than planned, or uses the inhalant over a longer period of time than planned. For instance, someone may begin using inhalants on school days, after initially limiting their use to weekends.
  • Inability to stop using. The person has either unsuccessfully attempted to cut down or stop using the inhalants, or has a persistent desire to stop using. Users may find that despite efforts to stop using inhalants on school days, they cannot stop.
  • Time. The affected person spends large amounts of time obtaining inhalants, using them, being under the influence of inhalants, and recovering from their effects. Obtaining the inhalants might not take up much time because they are readily available for little money, but the person may use them repeatedly for hours each day.
  • Interference with activities. The affected person either gives up or reduces the amount of time involved in recreational activities, social activities, and/or occupational activities because of the use of inhalants. The person may use inhalants instead of playing sports, spending time with friends, or going to work.
  • Harm to self. The person continues to use inhalants in spite of developing either a physical (liver damage or heart problems, for example) or psychological problem (such as depression or memory problems) that is caused by or made worse by the use of inhalants
  • INHALANT ABUSE. The DSM-IV-TR specifies that one or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for inhalant abuse:
  1. Interference with role fulfillment. The person’s use of inhalants frequently interferes with his or her ability to fulfill obligations at work, home, or school. People may find they are unable to do chores or pay attention in school because they are under the influence of inhalants.
  2. Danger to self. The person repeatedly uses inhalants in situations in which their influence may be physically hazardous (while driving a car, for example).
  3. Legal problems. The person has recurrent legal problems related to using inhalants (such as arrests for assaults while under the influence of inhalants).
  4. Social problems. The person continues to use inhalants despite repeated interpersonal or relationship problems caused by or made worse by the use of inhalants. For example, the affected person may get into arguments related to inhalant use
  • DSM-V Proposed Changes: adding “Inhalant-Use Disorder”
  • DSM-V Inhalant-Use Disorder Criteria:
  • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
  1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  4. 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
  • (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
  1. withdrawal, as manifested by either of the following:
  • a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
  • b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  • (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
  1. the substance is often taken in larger amounts or over a longer period than was intended
  2. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  4. important social, occupational, or recreational activities are given up or reduced because of substance use
  5. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  6. Craving or a strong desire or urge to use a specific substance.
  • Severity specifiers:
  • Moderate: 2-3 criteria positive
  • Severe: 4 or more criteria positive
  • Specify if:
  • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
  • Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)
  • Course specifiers (see text for definitions):
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • On Agonist Therapy
  • In a Controlled Environment

  • 19. Amphetamine Intoxication (282.89)

  • DSM-IV-TR criteria
  • A. Recent use of amohetamine or a related substance (e.g. methylphenidate).
  • B. Clinically significant maladaptive behavior or psychological changes (e.g. euporia or affective blunting; changes is sociability; hypervigilance;interpersonal sensitivity; anxiety; tension, or anger; stereotyped behaviors; impaired social or occupational functioning) that developed during, or shortly after, use of amphetamine or a related substance.
  • C. Two or more of the following, developing during, or shortly after, use of amphetamine or a related substance:
  • 1 tachycardia or bradycardia
  • 2 pupillary dilation
  • 3 elevated or lowered blood pressure
  • 4 perspiration or chills
  • 5 nausea or vomiting
  • 6 evidence of weight loss
  • 7 psychomotor agitation or retardation
  • 8 muscle weakness, respiratory depression, chest pain, or cardiac arrhythmias
  • 9 confusion, seizures, dykinesias, dystonias, or coma
  • D. The symptoms are not due to a general medical condition and are not better accounted for by another disorder
  • Specify if:
  • With Perceptual Disturbances
  • This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that the person knows that the hallucinations are induced by the substance and do not represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic Disorder, With Hallucinations, should be considered
  • Associated Features
  • After being intoxicated by recent use, there will be psychological and behavioral changes that will be significantly noticeable. Psychologically there may be some impairments of sociability and judgement There may be hostile or aggressive behavior depending on how much amphetamines were ingested. Hallucinations that are auditory or visual may occur and paranoia is also a possibility. It is actually fairly similar to schizophrenia . Hyperactivity and hypersexuality is also a common feature. The patient may have delusions such as feeling like there are insects crawling under their skin. The person may have issues with the law naturally due to the illegal nature of amphetamines. Their family and work life may suffer as well. There may be a presentation of very dull feelings along with sadness and social withdrawal. Fatigue, cardiac arrythmia, elevated or lowered blood pressure, dialation of the pupils, nausea or vomiting, or sweating and chills are some of the other issues that will probably show in the individuals during, or shortly after, they are intoxicated. Since amphetamines are highly addicting, it is very common for individuals to become addicted in a fairly short amount of time. This, of course, will ultimately lead to amphetamine dependence.
  • Child vs. adult presentation
  • Typically, it is rare for children to abuse amphetamines. It is much more common for children to accidentally ingest it than abuse it. For those rare cases of child amphetamine abuse, they will show similar symptoms. Adolescents and young adults, however, are among the highest users today.
  • Gender and cultural differences in presentation
  • Men are much more likely to abuse amphetamines than women. There is information that supports men enjoy amphetamines more than women due to the male body releasing 3 times as much dopamine. Different cultures that abuse amphetamines will show the same symptoms as Americans.
  • Epidemiology
  • Amphetamine intoxication can happen in any level of society and usually are used by individuals between the ages of 18 to 30 years old. It’s reported that about 8.8 million Americans alone will be intoxicated by some form of amphetamine in some point during their lifetimes. One of the most common, heavily abused amphetamine is methamphetamine. Reports have shown that a 30% increase in emergency room cases involving the use of methamphetamine from 1999 to 2000 alone, and the rates continue to climb.
  • Etiology
  • There is more supported evidence that this is environmentally influenced as opposed to biologically. Reseach has found that most use and abuse of amphetamines was started with the intent to aid them with weight loss. Others have been introduced through illegal drug experimentation. Low SES shows a high correlation with more intravenous use, which causes a quicker dependence on the amphetamine.
  • Empirically supported treatment
  • There is currently not a widely supported treatment for amphetamine abuse. One thing that is agreed upon is that it is not a good idea to treat amphetamine abuse with different medications. Since a prescribed medication may have caused the problem in the first place, it is easy to see prescribing more is not a smart idea. There is a little evidence that supports the drugs fluoxentine and imipramine as helpful alternatives, but more research is needed.
  • DSM-IV-TR criteria
  • A. Cessation of (or reduction in) amphetamine (or related substance) that has been heavy and prolonged.
  • B. Sysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion
  • 1 fatigue
  • 2 vivid, unpleasant dreams
  • 3 insomnia or hypersomnia
  • 4 increased appetite
  • 5 psychomotor retardation or agitation
  • C. The symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
  • Associated features
  • This happens when an individual who has reduced or discontinued the use of amphetamines that was originally used for a long time or in heavy amounts. The symptoms may vary depending on the level of dependence. Dysphoric mood and psychological changes such as fatigue, unpleasant dreams, trouble sleeping, and an increase in appetite will be noticeable. Depression or anxiety can be a very common part in withdrawal symptoms. Withdrawal can last from 3 days to 2 weeks depending on the severity.
  • Child vs. adult presentation
  • Children have been prescribed amphetamines for many different reasons throughout the years, but prodominately it was prescribed to them for the treatment of ADHD. Withdrawl symptoms in children have been known to be very slight because this prescribing for hyperactivity has been relatively stopped or regulated. More of the cases of amphetamine withdrawal is seen in adults because of the heavy recreational use of amphetamines such as ecstasy and methamphetamines. Adults have also been seen with more withdrawal symptoms because they use amphetamines for their success in helping drop the pounds.
  • Gender and cultural differences in presentation
  • There are no significant differences in males and females when it comes to withdrawal because it will be present in most cases, no matter how severe the symptoms are, if the individual has been using the drug heavily or for a prolonged amount of time. Culturally there are also no differences in the symptoms of amphetamine withdrawal throughout the world.
  • Epidemiology
  • Withdrawal can happen at any age or severity depending on how long and how much of the amphetamine has been used. It is only present when the individual reduces or stops the use, and it will continue to show its effects for as long as 2 weeks. Because of this, there are low success rates of overcoming the withdrawal symptoms since most choose to continue to use amphetamines in order to reverse the effects.
  • Etiology
  • This is only caused by environmental factors. It is specifically brought on by the lowered levels of amphetamines in the body once there has been a regulated tolerance for the substance in order to function. Environmental factors such as family or legal intervention might also play a role in developing the reason for the reduction or elimination of the use, which will spark the presentation of the withdrawal symptoms.
  • Empirically supported treatment
  • There are no specific medications that are used in effectively treating all of the withdrawal symptoms. Amphetamines have been studied as being a very good treatment, but there are conflicting reports as to how effective it is on reducing or eliminating the symptoms in order to let the individual overcome the addiction. Hospital detoxification is primarily the safest way to get through the symptoms and be closely evaluated especially for the chronic users, who may show significantly severe withdrawal symptoms.
  • Below is a video from the reality show Intervention, where families come together to help their loved ones with addiction. This video shows two females, the focus for this section is Amy, who is addicted to methamphetamine.

21. Caffeine Intoxication (305.9)

  1. DSM-IV-TR criteria
  • A Recent consumption of caffeine, usually in excess of 250mg (e.g. more than 2-3 cups of brewed coffee).
  • B Five or more of the following signs, developing during, or shortly after, caffeine use:
  1. restlessness
  2. nervousness
  3. excitement
  4. insomnia
  5. flushed face
  6. diuresis
  7. gastrointestinal disturbance
  8. muscle twitching
  9. rambling flow of thought and speech
  10. tachycardia or cardiac arrhythmia
  11. periods of inexhaustibility
  12. psychomotor agitation
  1. C The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • D The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. (e.g. Anxiety Disorder)
  • Tolerance to caffeine may be developed, so Caffeine Intoxication may not occur in certain individuals.
  1. DSM-IV-TR criteria for caffeine-induced anxiety disorder
  • Prominent anxiety predominates in the clinical picture.
  • There is evidence from the history, physical examination, or laboratory finding suggesting that the anxiety developed within 1 month of caffeine intoxication or withdrawal or that medications containing caffeine are etiologically related to the disturbance.
  • The disturbance is not bettr accounted for by an anxiety disorder that is not substance-induced.
  • The disturbance does not occur exclusively during the course of a dlirium.
  • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functiong.
  1. DSM-IV-TR criteria for caffeine-induced sleep disorder
  • A prominent disturbance in sleep occurs that is sufficiently severe to warrant independent clinical attention.
  • There is evidence from the history, physical examination, or laboratory findings that the sleep disturbance is the direct physiological consequence of caffeine consumption.
  • The disturbance is not better accounted for by another mental disorder.
  • The disturbance does not occur exclusively during the course of a delirium.
  • The disturbance does not meet the criteria for breathing-related sleep disorder or narcolepsy.
  • The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  1. DSM-IV-TR criteria for caffeine-related disorder NOS
  • This includes any caffeine disorder other than those previously listed.
  • Symptoms of caffeine withdrawal that are not currently an officially recognized diagnosis are present.
  1. Mental Status Examination
  • Many of the effects of caffeine consumption are expressed in behavioral manifestations. The most common is anxiety, with its associated fidgetiness, distractibility, poor eye contact, hesitating speech, and prolonged bursts of energy.
  • Caffeine’s effecton mood is complicated and not fully understood. Although initially it may promote some improvement in mood, notably identified by some slight euphoria or focused attention, this pattern may give way to a chronic dysphoria. This mildly depressed state may be a consequence of withidrawal.
  • Any complaint of sleep difficulty should include a careful assessment of beverage consumption.
  • Caffeine would not produce perceptual problems such as hallucinations.
  • Caffeine consumption does not produce alterations in thinking, such as delusions.
  • Caffeine consumption does not cause disorientation, memory problems, mental confusion, impairment in judgment, or problems with abstract thinking.
  1. Causes
  • The means by which caffeine exerts its pharmacologic effects remains a subject of active research.
  • A leading theory suggests that caffeine is an adenosine receptor antagonist that blocks two major types of adenosine receptors, A1AR and A2AAR.
  • Adenosine is an inhibitory neuromodulator affecting norepinephrine, dopamine, and serotonin activity.
  • Caffeine’s putative antagonism of adenosine would increase those neurotransmitters promotting psychostimulation.
  • The same neurotransmitter systems are implicated in the pathophysiology of several psychiatric.

22. Cannabis Intoxication (292.89)

  • DSM-IV-TR criteria
  • A. Recent use of cannabis.
  • B. Clinically significant maladaptive behavioral or psychological changes (e.g. impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use.
  • C. Two or more of the following signs, developing 2 hours of cannabis use:
  • conjuctival injection
  • increased appetite
  • dry mouth
  • tachycardia
  • D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
  • Specify if:
  • With Perceptual Disturbances
  • This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that the person knows that the hallucinations are induced by the substance and do not represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic Disorder, With Hallucinations, should be considered
  • When cannabis is smoked, intoxication develops within minutes; however, if cannabis is ingested orally, intoxication may take a few hours to develop.
  • Effects of cannabis intoxication usually last 3-4 hours. The effects may last longer if the cannabis was ingested orally.
  • The behavioral and psychological changes that occur depend of the dose, the administration, and the individual. For example, a person’s tolerance, rate of absorption and sensitivity will differ greatly 23. Other (or Unknown) Substance-Related Disorders
  • A list of the Other (or Unknown) Substance-Use Disorders and the Other (or Unknown) Substance-Induced Disorders
  • Definition
  • This is a category of classification when the substances associated with the disorder are not covered by the 11 categories the DSM-IV-TR uses to classify Substance-Related Disorders. Substances that may relate to the disorder but are not covered include anabolic steroids, nitrite inhalants, nitrous oxide, catnip, betel nut, and kava. The disorders are generally described with the disorder that they share phenomenology with.
  • Other (or Unknown) Substance-Use Disorders
  • Other (or Unknown) Substance Dependence 304.9
  • Other (or Unknown) Substance Abuse 305.9
  • Other (or Unknown) Substance-Induced Disorders
  • Other (or Unknown) Substance Intoxication 292.89 Specify if: With Perceptual Disturbances
  • Other (or Unknown) Substance Withdrawal 292.0 Specify if: With Perceptual Disturbances
  • Other (or Unknown) Substance-Induced Delirium 292.81
  • Other (or Unknown) Substance-Induced Persisting Dementia 292.82
  • Other (or Unknown) Substance-Induced Persisting Amnestic Disorder 292.83
  • Other (or Unknown) Substance-Induced Psychotic Disorder, with Delusions 292.11 Specify if: With Onset During Intoxication/With Onset During Withdrawal
  • Other (or Unknown) Substance-Induced Psychotic Disorder, with Hallucinations 292.12 Specify if: With Onset During Intoxication/With Onset During Withdrawal
  • Other (or Unknown) Substance-Induced Mood Disorder 292.84 Specify if: With Onset During Intoxication/With Onset During Withdrawal
  • Other (or Unknown) Substance-Induced Anxiety Disorder 292.89 Specify if: With Onset During Intoxication/With Onset During Withdrawal
  • Other (or Unknown) Substance-Induced Sexual Dysfunction 292.89 Specify if: With Onset During Intoxication
  • Other (or Unknown) Substance-Induced Sleep Disorder 292.85 Specify if: With Onset During Intoxication/With Onset During Withdrawal
  • Other (or Unknown) Substance-Related Disorder Not Otherwise Specified 292.9

SOCIAL ISSUES RELATED TO SUBSTANCE USE AND ABUSE

  • Pregnancy and Substance Abuse
  • Rates of women who abuse substances are increasing. Most of the women who abuse substances are of child bearing ages. This presents a number of unique, complex and socially relevant issues. Including
  • • Effects on children of substances used during the pregnancy.
  • • Effects of attachment and mothering- state issues related to child-rearing
  • • Effects of possible HIV infection due to contaminated needle usage during and after pregnancy
  • Treating professionals must also be aware of ethical issues related to suspicions of substance use on the part of a mother. These ethical concerns center around whether the mother is doing harm to an unborn child and whether the professional has a duty to warn social services agencies. Further, in terms of physical health physicians also must weigh to whom they have a duty to treat in the best interest of the mother or the unborn child.
  • Maternal consumption of alcohol and other drugs during any time of pregnancy can cause birth defects or neurological deficits.
  • Alcohol
  • Alcohol use by a woman who is pregnant is said to affect the fetus in a dose dependent manner. With “very high repetitive doses” there is a 6-10% chance of the fetus developing the fetal alcoholic syndrome manifested by prenatal and postnatal growth deficiency, specific craniofacial dysmorphic features, mental retardation, behavioral changes and a variety of major anomalies (Ornoy & Ergaz, 2010).
  • Cognitive performance is less affected by alcohol exposure in infants and children whose mothers stopped drinking in early pregnancy, despite the mothers’ resumption of alcohol use after giving birth.
  • Prenatal alcohol effects have been detected at moderate levels of alcohol consumption in nonalcoholic women. Even though a mother may not regularly abuse alcohol, her child may not be spared the effects of prenatal alcohol exposure
  • Offspring of mothers using ethanol during pregnancy can suffer from developmental delays and/or behavioral difficulties. High repetitive doses of alcohol 6-10% chance of fetus developing the fetal alcoholic syndrome manifested by prenatal and post natal growth deficiency, specific craniofacial dysmorphic features, mental retardation, and other major anomalies. Even with lower repetitive doses risk of slight intellectual impairment, growth disturbances and behavioral changes. Binge drinking imposes danger of slight intellectual deficiency. (Ornoy A, Ergaz Z.)
  • Studies were done on 12 year olds exposed to tobacco versus to 12 year olds unexposed to compare brain function. Researchers found that children who were prenatally exposed to tobacco show increased rates of behavior problems related to response inhibition deficits.
  • Methamphetamines
  • Children that are born to women who use methamphetamines are more likely to experience preterm delivers, have lower Apgar scores, increase rates of cesarean delivery and increased neonatal mortality (Good MM, et., al, 2010)
  • Cocaine
  • • Studies have shown that exposure to cocaine during fetal development may lead to subtle but significant deficits later on, especially with behaviors that are crucial to success in the classroom, such as blocking out distractions and concentrating for long periods.Children ages four to nine whose parents had used cocaine were studied to measure their cognitive abilities. The study showed that gender effected the outcome because boys whose mothers who used cocaine had lower IQ scores, and placed boys at risk for problems of inhibitory control, emotional regulation, and antisocial behavior (Bennett, D., et., al, 2008).
  • It was also found that children exposed to cocaine during the first trimester were smaller on all growth parameters than the children who were not exposed to cocaine during the first trimester.
  • The results of these studies also indicate cocaine associated deficits in attention processing through the age 7.
  • It was also found that boys who were prenatally exposed to cocaine reported engaging in more high-risk behaviors
  • Tobacco
  • Smoking during pregnancy most prevalent risk factor (Burstyn I, Kapur N Cherry NM.
  • Attachment difficulties appear if mother is incarcerated secondary to drug usage. (Cassidy J, Ziv Y, Stupica B, Sherman LJ, Butler H, Karfgin A, Cooper G, Hoffman KT, Powell B.
  • HIV
  • For women who have drug-usage related HIV treatment for drug abuse during pregnancy which can include methadone and buprenorphine may have drug interactions withHIV medicaltions, and HIV medicatins. ( mcCance-Katz EF)
  • Treatment include several integrated programs that have been specifically developed to meet the needs of pregnant and parenting women with substance abuse issues. These programs are aimed more specifically at the needs of the children and to educate them about the damages to the children caused by the substance. Evidence shows that these programs are indeed effective but no more effective than regular treatment programs for women who abuse substance ( Milligan, K., et., al, 2010).

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