Chapter 12 - Substand-Related Disorders.doc

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University of Toronto Scarborough
Konstantine Zakzanis

Chapter 12SubstanceRelated Disorders from prehistoric times humankind has used various substances in the hope of reducing physical pain or altering states of consciousness almost all peoples have discovered some intoxicant that affects the CNS relieving physical and mental anguish or producing euphoria despite the often devastating consequences of taking such substances into the body their initial effects are usually pleasing a factor that is perhaps the root of substance abuse North America is a drug culture North Americans use drugs to wake up caffeine in coffee or tea to stay alert throughout the day nicotine in cigarettes caffeine in soft drinks to relax alcohol and to reduce pain aspirinthe pathological use of substances falls into 2 categories substance abuse and substance dependencesubstance dependencethe abuse of a drug sometimes accompanied by a physiological dependence on it made evident by tolerance and withdrawal symptoms also called addiction substance dependence is characterized by DSMIVTR as the presence of at least 3 of the followingthe person develops tolerance indicated by either a larger doses of the substance being needed to produce the desired affect or b the effects of the drug becoming markedly less if the usual amount is taken tolerancea physiological process in which greater and greater amounts of an addictive drug are required to produce the same effectwithdrawal symptomsnegative physical and physiological effectsdevelop when the person stops taking the substance or reduces the amount the person may also use the substance to relive or avoid withdrawal symptoms withdrawalnegative physiological and psychological reactions evidenced when a person suddenly stops taking an addictive drug cramps restlessness and even death are examplesthe person uses more of the substance or uses it for a longer time than intendedthe person recognizes excessive use of the substance heshe may have tried to reduce usage but has been unable to do somuch of the persons time is spent in efforts to obtain the substance or recover from its effectssubstance use continues despite psychological or physical problems caused or exacerbated worsened by the drug eg smoking despite knowing that it increases the risk for cancer and cardiovascular diseasethe person gives up or cuts back participation in many activities work recreation socializing because of the use the substancesubstance dependence is diagnosed as being accompanied by physiological dependence also called dependence if either tolerance or withdrawal is present in general physical dependence on a drug is associated with more severe problems substance abusethe use of a drug to such an extent that the person is often intoxicated throughout the day and fails in important obligations and in attempts to abstain but there is no physiological dependence for the less serious diagnosis of substance abuse the person must experience one of the following as a result of the recurrent use of the drugfailure to fulfill major obligations eg absences from work or neglect of childrenexposure to physical dangers eg operating machinery or driving while intoxicatedlegal problems eg arrests for disorderly conduct or traffic violationspersistent social or interpersonal problems eg arguments with a spouse the DSMIVTR section on substancerelated disorders includes several other diagnosessubstance intoxication is diagnosed when the ingestion of a substance affects the CNS and produces maladaptive cognitive and behavioral effects if a person addicted to a drug is denied it and then experiences withdrawal that person receives a diagnosis of both substance dependence and substance withdrawal an example of substance withdrawal is alcohol withdrawal delirium commonly known as DTs delirium tremensdelirium tremens DTsone of the withdrawal symptoms that sometimes occurs when a period of heavy alcohol consumption is terminated marked by fever sweating trembling cognitive impairment and hallucinations Alcohol Abuse and Dependence DSMIVTR distinguishes between alcohol dependence and alcohol abuse the term abuse is often used to refer to both aspects of the excessive and harmful use of alcohol alcohol dependence may include tolerance or withdrawal reactions people who are physical dependence on alcohol generally have more severe symptoms of the disorderst those who begin drinking early in life develop their 1 withdrawal symptoms in their 30s or 40s the effects of the abrupt withdrawal of alcohol in a chronic heavy user may dramatic because the body has become accustomed to the drug subjectively the patient is often anxious depressed weak restless and unable to sleep tremors of the muscle especially of the small musculatures of the fingers face eyelids lips and tongue may be marked and pulse blood pressure and temperature are elevated in relatively rare cases a person who has been drinking heavily for a number of years may also experience delirium tremens when the level of alcohol in the blood drops suddenly the person becomes delirious as well as tremulous and has hallucinations that are primarily visual but may be tactile as well the delirium and physiological paroxysms caused by withdrawal of alcohol indicate that the drug is addictive increased tolerance is evident following heavy prolonged drinking levels of alcohol in the blood of excessive drinkers are unexpectedly low after what is viewed as excessive drinking suggesting that the body adapts to the drug and becomes able to process it more efficiently some research suggests that tolerance results from changes in the number or sensitivity of GABA or glutamate receptors withdrawal may be the result of increased activation in some neural pathways to compensate for alcohols inhibitory effects in the brain when drinking stops the inhibitory effects of alcohol are lost resulting in a state of over excitation some people from Waterloo have highlighted the role of psychological factors response expectations and the consequences of behavior can have a direct influence on tolerance and the effects of alcohol the development of addictions often reflects the interplay of biological and psychological factors the drinking pattern of people who are alcohol dependent indicates that their drinking is out of control the person who abuses alcohol in contrast to the person physically dependent on it experiences negative social and occupational effects from the drug but does not show tolerance withdrawal or the compulsive drinking patterns seen in the person who is alcohol dependentalcohol abuse or dependent is often part of polydrug or polysubstance abuse using or abusing more than 1 drug at a time
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