Ch. 17 - Substance abuse disorders.

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10 Jan 2011
Lecture 9: Substance Abuse Disorders (Ch. 17) Nov. 24, 09
DSM-IV Disorders
There are four substance use disorders recognized by the DSM –IV
-Substance intoxication
-Substance abuse
-Substance dependence
-Substance withdrawal
The vast majority of people will try one type of ~substance~ at least once
Substance intoxication
-Development of reversible symptoms and maladaptive behavioural or psychological changes
due to the direct physiological effects of a substance on the CNS
EX: sedatives have a direct impact on wakefulness; acid has an impact on
neurophysiologic processes; marijuana has an effect on attention/thinking processes;
cocaine has an impact on move-ability; amphetamines have a direct impact on
psychomotor agitation; alcohol on judgement and control
-Only diagnosed if the behavioural and psychological changes cause significant disruption in
the person’s life or place the person at risk of adverse effects (like accidents or physical
Factors affecting intoxication
-Type of substance
- Alcohol vs. opiates vs. amphetamines; different impact
- Crack/cocaine taken up quickly and efficiently (intense
but short lived) hence people will try to ‘follow it
quickly very addictive
Different methods; snort, smoke, inject, oral ingestion
Can affect system faster or slower; snorting/smoking have
more direct impact on CNS and person will appear more
-History of use
- Differences in how they get intoxicated
-Tolerance – related to body size (smaller=more intensely intoxicated), gender (female=more
intoxicated), history of use (long history, tolerance builds up so more drug is required to
build high), drug metabolism (individual variation in how different people metabolize drugs)
-Expectations of use
-Environment or setting in which substance is ingested
- If a person is used to alcohol or using heroine in the same setting at the same dose, if they
change environment then there might be an overdose; perhaps because some cues triggered
an opposite process while the new environment doesn’t
Substance Abuse
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-Recurrent and significant adverse consequences related to substance use (i.e. mostly
social/legal consequences)
-The presence of one or more recurrent symptoms in a 12 month period
- Failure to fulfill role obligations (like missing classes because of using drug/recovering
effects, missing work, not taking care of household responsibilities)
- Use in hazardous situations (like drinking and driving)
- Legal problems (getting arrested for drinking+driving, getting into physical fights while
- Social or interpersonal problems (friends/family nagging you about substance abuse)
Criteria for substance abuse disorder is very strict (like missing a class twice in a year b/c of
getting hungover meets the criteria for substance abuse) hence it isn’t always effective in
diagnosing people
That’s why people usually use their own critical judgement when making diagnoses
Another problem: many legal drugs (like cigarettes/painkillers) can be abused but may not
meet these criteria
Substance Dependence
- Pattern of compulsive use despite significant substance related problems
- The presence of 3 or more in a twelve month period:
-Tolerance (quantity used increases over time in order to have same effects)
Varies across drugs; there is definitely tolerance that builds over time for opiates and
alcohol, but not really for marijuana
-Withdrawal (symptoms experienced when they stop taking the drug/medication or having to
take the substance in order to prevent physical symptoms from starting)
Like if you stop taking anti-anxiety pills, you get a rebound of anxiety; or getting hung-
over from last night and drinking more alcohol in the morning to stop those symptoms
Vary a lot across different substances; very marked for alcohol, sedatives, opiates but
more moderate for nicotine and amphetamines, and none for hallucinogens
-Ingest more or over longer period than intended
like planning to have an early night but end up drinking 6 bottles of beer
-Persistent desire or unsuccessful effort to cut down
they may be able to cut down for a couple days, but their psychological/physiological
dependence is too strong so they relapse
-Much time spent obtaining, using, or recovering (from effects)
- Like person who’s addicted to painkillers goes from doctor to doctor trying to get
- Or person trying to track down money in order to get substance (obtaining)
- Or chain smokes (using)
- Sleeping off the effects of ecstasy for the whole day (recovering)
-Reduce social, occupational, or recreational activities
Stop making plans with people, spending time with family, etc
-Continued use despite knowledge of the psychological and/or physical consequences
Continuing to drink despite knowing one has a stomach ulcer or it makes one depressed
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Symptoms have to be fairly recurrent
Substance Withdrawal
-Involves a set of maladaptive physiological and behavioural symptoms that result when
people who’ve been using substances heavily for prolonged periods stop
Symptoms can become even more intense over the first couple of days of withdrawal (like
seizures which occur with anxiolitics)
- Can be dangerous without medical assistance
Alcohol Intoxication
-Alcohol is a central nervous system depressant
-Physical effects occur in stages:
~ Frontal lobes – affects reasoning, memory, judgment, and inhibition
~ Cerebellum – affects motor control, balance, and speech (hence tests for blood alcohol
level like walking in straight line and talking)
~ Spinal cord and medulla – affect breathing, body temp and heart rate (when taken in higher
Even though people may appear stimulated at first, alcohol has an overall
depressant effect (especially in high doses)
0.5% or greater, can lead to death through respiratory paralysis; the highly
depressant effects associated with high doses are dangerous
-Blood alcohol content [BAC] of 0.5% or more can lead to death (legal limit: BAC=0.08%)
-Also many cognitive effects; like people forgetting what happened when they were
intoxicated (maybe it’s difficult to remember things learned while intoxicated but can
remember them when they’re intoxicated again)
-Less likely to get intoxicated from alcohol when done with a full stomach
Alcohol Abuse/Dependence
- Abuse
-Use alcohol in dangerous situations, fail to meet obligations at work or at home due to
alcohol use, and/or recurrent legal or social problems as result of alcohol use
- Dependence
-Physiological or psychological dependence, spend a lot of time intoxicated or in withdrawal,
or continue to drink despite significant legal, social, medical, or occupational problems
Different Patterns:
- Period of abstinence but will go on long drinking binges
- Drinking all the time
- People who don’t drink during the days but will limit drinking to evenings or weekends (but still
Alcohol Withdrawal
3 stages of severe withdrawal (from severe dependence):
-1 – tremors, weakness, and profuse perspiration within a few hours of the last drink
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