Substance-Related Disorders

Substance Related Disorders
• Alemayehu Negash, MD, PhD,

• Chair Person, Department of
Psychiatry
• Assistant Professor and
• Consultant Psychiatrist
T h e Substance Related disorders encompass 10
separate classes of drugs
These 10 classes are not fully distinct.
All drugs that are taken in excess have in common

direct activation of the brain reward system
The Reward system involves:
1. the reinforcement of behaviors and
2. the production of memories.
alcohol, inhalants,
cannabis, hallucinogens,
Nicotine, phencyclidine [PCP],

Addictive Behaviors
cocaine,
 Gambling
amphetamines,
 Sex Addiction
caffeine,
 Internet Addiction
opioids,
 Exercise
 sedative hypnotic
 Shopping Addiction
Drugs typically activate the reward system and

produce feelings of pleasure (high).
The drugs of abuse directly activate the reward
pathways.
• Individuals with lower levels of self-control, may
have impairments of brain inhibitory mechanisms
Such Individuals can be particularly at risk to

development of substance use disorders,
So, the roots of substance use disorders for some
persons can be seen in their behaviors long before
the onset of actual substance use itself.
Two broad categories:
1. Substance use disorders
2. Substance Induced Disorders

SUBSTANCE INDUCED DISORDERS
1. intoxication,
2. withdrawal, and
3. other substance/medication-induced mentalDisorders
i. psychotic disorders,
ii. bipolar and related disorders,

iii. depressive disorders,
iv. anxiety disorders,
v. obsessive-compulsive and related disorders,

vi. sleep disorders,
vii. sexual dysfunctions,

viii. delirium, and
ix. neurocognitive disorders

Substance Use Disorders
 The essential feature of a substance use disorder entails
• a cluster of
1. cognitive,
2. behavioral, and
3. physiological
symptoms must be found to make a
diagnosis
These cluster of symptoms must indicate that the

individual continues using the substance despite
significant substance-related problems.
The diagnosis of a substance use disorder can be
applied to all 11 classes except caffeine.
For certain classes some symptoms are less salient,
and in a few instances not all symptoms apply
• For example withdrawal symptoms are not
specified for phencyclidine use disorder, other
hallucinogen use disorder, or inhalant use
disorder
An important characteristic of substance use
disorders is an underlying change in brain circuits
The underlying change in brain may persist
beyond detoxification disorders
The behavioral effects of these brain changes may
be exhibited in the repeated relapses and intense
drug craving when the individuals are exposed to
drug-related stimuli.
These persistent drug effects may benefit from long-
term approaches to treatment.
• The diagnosis of a substance use disorder is based on a
pathological pattern of behaviors related to use of the
substance.
Diagnostic Criteria organization.
• Criterion A: criteria can be considered to fit within overall
groupings of
i. impaired control,
ii. social impairment,
iii. risky use, and
iv.pharmacological criteria.
• Impaired control over substance use is the first
criteria grouping (Criteria 1-4).
Criterion 1: The individual may take the substance in
larger amounts or over a longer period
than was originally intended
Criterion 2: The individual may express a persistent
desire to cut down or regulate substance
use and may report multiple unsuccessful
efforts to decrease or discontinue use
Criterion 3: The individual may spend a great deal
of time obtaining the substance, using the
substance, or recovering from its effects.
• In some instances of more sere substance use
disorders, virtually all of the individual's daily
activities revolve around the substance.
• Criterion 4: Craving is manifested by intense
desire or urge for the drug that may
occur at any time but is more likely when
in an environment where the drug
previously was obtained or used.
• Craving has also been shown to involve classical
conditioning and is associated with activation of
specific reward structures in the brain.
Current craving is often used as a treatment outcome
measure because it may be a signal of impending
relapse.
Social impairment is the second grouping of
criteria (Criteria 5-7).
Criterion 5: Recurrent substance use may result in a
failure to fulfill major role obligations at
work, school, or home
Criterion 6: The individual may continue substance
use despite having persistent or
recurrent social or interpersonal
problems caused or exacerbated by the
effects of the substance
Criterion7: Important social, occupational, or
recreational activities may be given up or
markedly reduced because of substance use.
The individual may withdraw from family activities
and hobbies in order to use the substance.
Risky use of the substance is the third
grouping of criteria (Criteria 8-9).
Criterion 8: Risky use may take the form of recurrent
substance use in situations in which it is physically
hazardous
Criterion 9: The individual may continue substance
use despite knowledge of having a persistent or
recurrent physical or psychological problem that is
likely to have been caused or exacerbated by the
substance
The key issue in evaluating this criterion is not the
existence of the problem, but rather the individual's
failure to abstain from using the substance despite
the difficulty it is causing.
Substance-Related Disorders
Pharmacological criteria are the final
grouping (Criteria 10 and 11).
Criterion 10: Tolerance is signaled by requiring

a markedly increased dose of the substance to
achieve the desired effect or a markedly
reduced effect when the usual dose is
consumed.
Criterion 11: Withdrawal is a syndrome that occurs
when blood or tissue concentrations of a substance
decline in an individual who had maintained
prolonged heavy use of the substance.
• During developed withdrawal symptoms, the
individual is likely to consume the substance to
relieve the symptoms.
Withdrawal symptoms vary greatly across the
classes of substances, and separate criteria sets for
withdrawal are provided for the drug classes.
Marked and generally easily measured
physiological signs of withdrawal are common with
alcohol,
opioids,
sedatives,
hypnotics, and
anxiolytics
• Withdrawal signs and symptoms with stimulants
(amphetamines and cocaine), as well as tobacco and
cannabis, are often present but can be less apparent
• Significant withdrawal has not been demonstrated
after repeated use of phencyclidine, other
hallucinogens, and inhalants;
Therefore, this criterion is not included for these
substances.
• Neither tolerance nor withdrawal is necessary for a
diagnosis of a substance use disorder.
• However, for most classes of substances,
1. a past history of withdrawal
2. an earlier onset of a substance use disorder,

3. higher levels of substance intake, and
4. a greater number of substance-related problems
are associated with a more severe clinical course

• Substance use disorders occur with severity based
on the number of symptom criteria endorsed.
• A general estimate of severity

1. mild substance use disorder: two to three
symptoms,
2. Moderate: four to five symptoms, and
3. Severe: six or more symptoms.

4. Changing severity across time: as reflected by
reductions or increases in the frequency and/or
dose of substance use,
Assessment
1. individual's own report,
2. report of knowledgeable others,

3. clinician's observations, and
4. biological testing.
 Course specifiers and descriptive features
1. in early remission,
2. in sustained remission,
3. on maintenance therapy, and

4. in a controlled environment
• Definitions of each are provided within respective
criteria sets.
• Substance-Induced Disorders
Substance Intoxication and Withdrawal
• Criterion A: The essential feature is the
development of a reversible substance-
specific syndrome due to the recent ingestion
of a substance
• Criterion B: There are clinically significant problematic
behavioral or psychological changes
associated with intoxication (e.g. belligerence,
mood lability, impaired judgment)
are attributable to the physiological effects of the
substance on the CNS and develop during or shortly
after use of the substance
• Symptoms of tolerance and withdrawal occurring
during appropriate medical treatment with prescribed
drug/substance are specifically not counted when
diagnosing a substance use disorder.
• Criterion D: The symptoms are not attributable to
another medical condition and are not better
explained by another mental disorder
• Substance intoxication is common among those with
a substance use disorder but also occurs frequently
in individuals without a substance use disorder.
This category does not apply to tobacco.
• The most common changes during intoxication are
disturbances of
1. perception,
2. wakefulness,
3. attention,
4. thinking,
5. . judgment,
6. psychomotor behavior, and
7. interpersonal behavior
 Short-term, or "acute," intoxications may have different
signs and symptoms than Sustained Intoxication, or
"chronic," intoxications.
• For example, moderate cocaine doses may initially
produce sociability, but social withdrawal may
develop if such doses are frequently repeated over
days or weeks.
Withdrawal Syndrome
• The essential feature is the development of a substance-
specific problematic behavioral change, with physiological
and cognitive concomitants,
• Criterion A: Withdrawal is due to the cessation of, or
reduction in, heavy and prolonged substance use
• Criterion C: The substance-specific syndrome causes
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
• (Criterion D): The symptoms are not due to another
medical condition and are not better
explained by another mental disorder
• Withdrawal is usually, but not always, associated with
a substance use disorder.
• Most individuals with withdrawal have an urge to re-
administer the substance to reduce the symptoms.
• Route of Administration and Speed of
Substance Effects
• Routes of administration that produce more rapid and
efficient absorption into the bloodstream
1. Intravenous,
2. smoking,
3. intranasal "snorting“.
– Rapidly acting substances are more likely to produce
immediate intoxication.
• Duration of Effects
• Within the same drug category: relatively short-acting
substances tend to have a higher potential for the
development of withdrawal.
• In general, the longer the acute withdrawal period, the

less intense the syndrome tends to be
• The half-life of the substance of abuse parallels
aspects of withdrawal: the longer the duration of
action, the longer the time between cessation and the
onset of withdrawal symptoms and the longer the
withdrawal duration.
• Associated Laboratory Findings
• Laboratory analyses of blood and urine samples can
help determine recent use and the specific substances
involved.
• A positive laboratory test result does not indicate a
pattern of substance use,
• A negative test result does not by itself rule out a
diagnosis as well.
• Laboratory tests can be useful in identifying
withdrawal.
• If the individual presents with withdrawal from an
unknown substance, laboratory tests may help identify
the substance and may also be helpful in
differentiating withdrawal from other mental disorders.
• Normal functioning in the presence of high blood levels of
a substance suggests considerable tolerance
• Development and Course

• Individuals ages 18-24 years have relatively high
prevalence rates for the use of virtually every substance.
• Intoxication is usually the initial substance-related
disorder and often begins in the teens.
• Withdrawal can occur at any age as long as the relevant
drug has been taken in sufficient doses
Substance/Medication-Induced Mental
Disorders
• The substance/medication-induced mental disorders are
potentially severe and usually temporary problems
• Sometimes they are persisting CNS syndromes
• They develop in the context of the effects of substances of

abuse, medications, or several toxins.
They are distinguished from the substance use
disorders, in which a cluster of
1. cognitive,
2. behavioral, and
3. physiological symptoms
contribute to the continued use of a substance
despite significant substance-related problems.
• The substance/medication-induced mental disorders
may be induced by the 11 classes of substances that
produce substance use disorders, or by a great
variety of other medications used in medical
treatment.
 All substance/medication-induced disorders share
common characteristics.
 Therefore, it is important to recognize these common
features to aid in the detection of these disorders.
 These features are described as follows:
A. The disorder represents a clinically significant symptomatic
presentation of a relevant mental disorder.
B. There is evidence from the history, physical examination, or

laboratory findings or both of the following:
1. The disorder developed during or within 1 month period of a
substance intoxication or withdrawal or taking a medication; and
2. The involved substance/medication is capable of producing the
mental disorder, after the cessation of acute withdrawal or severe
intoxication or taking the medication.
C. The disorder is not better explained by an independent mental
disorder (i.e., one that is not substance- or medication-induced).
Such evidence of an independent mental disorder includes the

following:
• 1. The disorder preceded the onset of severe intoxication or
withdrawal or exposure to the medication; or

• 2. The full mental disorder persisted for a substantial period of time
(e.g., at least 1 month)
• This criterion does not apply to substance-induced
neurocognitive disorders or hallucinogen persisting
perception disorder
• Substance-induced neurocognitive disorders or
hallucinogen persisting perception disorder, persist
beyond the cessation of acute intoxication or
withdrawal.
• D. The disorder does not occur solely during the
course of a delirium.
• The disorder causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
• Features
• The categories of substances capable of producing
clinically relevant substance-induced mental disorders:
1. the more sedating drugs
2. the more stimulating substances (e.g.,
amphetamines and cocaine)
• The medication-induced conditions include often
idiosyncratic CNS reactions or relatively extreme
examples of side effects for a wide range of
medications taken for a variety of medical concerns.
• These include neurocognitive complications of
1. anesthetics,
2. antihistamines,
3. antihypertensives,
4. other medications and toxins (e.g., organophosphates,
insecticides, carbon monoxide),
Psychotic syndromes may be temporarily
experienced in the context of
1. anticholinergic
2. cardiovascular, and
3. steroid drugs, as well as during
4. use of stimulant-like
5. and depressant-like prescription or
6. over-the-counter drugs.
• Temporary but severe mood disturbances can be
observed with a wide range of medications, including
1. steroids,
2. antihypertensives,
3. disulfiram, and
4. any prescription or over-the-counter depressant or

stimulant-like substances.
• A similar range of medications can be associated
with temporary
1. anxiety syndromes,
2. sexual dysfunctions, and
3. disturbed sleep.
• In general, to be considered a substance/medication-
induced mental disorder, there must be evidence that
the disorder being observed is not likely to be better
explained by an independent mental condition.
• The independent mental conditions are most likely to
be seen if the mental disorder was present before the
severe intoxication, withdrawal, medication
administration, or
• The exception is several substance-induced persisting
disorders and
• the psychiatric syndrome occurring during the
delirium should not also be diagnosed separately
• Many such psychiatric syndromes are commonly seen
during agitated, states of delirium.
The features associated with each relevant major
mental disorder are similar whether observed with
• independent or substance/medication-induced mental
disorders.
• However, individuals with substance/medication-
induced mental disorders are likely also to
demonstrate the associated features seen with the
specific category of substance or medication
• Substance-induced mental disorders develop in the
context of
1. intoxication or withdrawal from substances of
abuse, and
2. medication-induced mental disorders, or

prescribed or over-the-counter medications
that are taken at the suggested doses.
• Both conditions are usually temporary and likely to
disappear within 1 month or so of
1. cessation of acute withdrawal,

2. severe intoxication, or
3. use of the medication.

: substance-associated neurocognitive disorders
are related to
1. alcohol-induced neurocognitive disorder,
2. inhalant-induced neurocognitive disorder, and
3. sedative-, hypnotic-, or anxiolytic-induced
neurocognitive disorder;
4. and hallucinogen persisting perception disorder
("flashbacks“);
• . Most other substance/medication-induced mental

disorders, are likely to improve relatively quickly with
abstinence and unlikely to remain clinically relevant for
more than 1 month after complete cessation of use.
• The intake of substances of abuse or some medications
with psychiatric side effects in the context of a
preexisting mental disorder is likely to result in an
intensification of the preexisting independent
syndrome.
• The risk for substance/medication-induced mental
disorders is likely to increase with both the quantity
and the frequency of consumption
• Substance-induced mental disorders develop in the
context of intoxication or withdrawal from substances
of abuse
• They are also seen in intoxication or withdrawal from
prescribed or over-the-counter medications that are
taken at the suggested doses.
• Both conditions are usually temporary and likely to
disappear within 1 month or so of
1. cessation of acute withdrawal,

2. severe intoxication, or
3. use of the medication.

• Exceptions to these generalizations
certain long-duration substance-induced disorders:
substance-associated neurocognitive disorders are
relate to
1. Alcohol intake (alcohol-induced neurocognitive
disorder),
2. Inhalants (inhalant-induced neurocognitive disorder,
and sedative-, hypnotic-, or anxiolytic-induced
neurocognitive disorder; and)
4. Hallucinogens (hallucinogen persisting perception)
disorder "flashbacks";).
• However, most other substance/medication-induced
mental disorders, are likely to improve relatively
quickly with abstinence.
• Its unlikely that they remain clinically relevant for
more than 1 month after complete cessation of

use.
• Symptoms of substance/medication-induced mental
disorders can be identical to those of independent
mental disorders (e.g., delusions, hallucinations,
psychoses, major depressive episodes, anxiety
syndromes), and they can have the same severe
consequences (e.g., suicide)
• However, most induced mental disorders are likely to
improve in a matter of days to weeks of abstinence
• The substance/medication-induced mental disorders
are an important part of the differential diagnoses for
the independent psychiatric conditions
• Symptoms of substance/medication-induced mental
disorders may be identical cross-sectionally to those of
independent mental disorders but have different
treatments and prognoses from the independent
condition.
Alcohol-Related Disorders
• Alcohol Use Disorders
1. Alcohol Use Disorder
2. Alcohol Intoxication
3. Alcohol Withdrawal
4. Other Alcohol-induced Disorders
5. Unspecified Alcohol-Related Disorder
• Diagnostic Criteria
• A. A problematic pattern of alcohol use leading to clinically
significant impairment or distress, as manifested by at least
two of the following, occurring within a 12-month period:
1. Alcohol 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 alcohol use.
3. A great deal of time is spent in activities necessary to
obtain alcohol, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.

5. Recurrent alcohol use resulting in a failure to fulfill major
role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities

are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is
physically hazardous.
9. Alcohol 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 alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to
achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of
the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol
b. Alcohol (or a closely related substance, such as a
benzodiazepine) is taken to relieve or avoid
withdrawal symptoms.
• early remission: (for at least 3 months but for
• less than 12 months with the exception that Criterion A4,
“Craving, or a strong desire or urge to use alcohol,” may be
met).
• In sustained remission: none of the criteria for alcohol use
disorder have been met at any time during a period of 12
months or longer or Criterion A4 may be met
• In a controlled environment:
• Symptoms of conduct problems, depression, anxiety,
and insomnia frequently accompany heavy drinking and
sometimes precede it.
• Repeated intake of high doses of alcohol can affect nearly
every organ system, especially the gastrointestinal tract,
cardiovascular system, and the central and peripheral
nervous systems.
• Gastrointestinal effects include gastritis, stomach or
duodenal ulcers, and, in about 15% of individuals
who use alcohol heavily, liver cirrhosis and/or
pancreatitis.
• There is also an increased rate of cancer of the
esophagus, stomach, and other parts of the
gastrointestinal tract.
• One of the most commonly associated conditions is
low-grade hypertension.
• Marked increases in levels of triglycerides and low-
density lipoprotein cholesterol, contribute to an elevated
risk of heart disease.
• Peripheral neuropathy may be evidenced by muscular
weakness, paresthesias, and decreased peripheral
sensation.
• More persistent central nervous system effects include
cognitive deficits, severe memory impairment, and
degenerative changes in the cerebellum.
• These effects are related to the direct effects of alcohol or
• of trauma and to vitamin deficiencies (particularly of the
B vitamins, including thiamine).
• One devastating central nervous system effect is the
relatively rare alcohol-induced persisting
• amnestic disorder, or Wemicke-Korsakoff syndrome, in
which the ability to encode new memory is severely
impaired.
• Alcohol use disorder is an important contributor to
suicide risk during severe intoxication and in the
context of a temporary alcohol-induced depressive and
bipolar disorder.
• There is an increased rate of suicidal behavior as well
as of completed suicide among individuals with the
disorder
Prevalence
• Alcohol use disorder is a common disorder
• Twelve-month prevalence of alcohol use disorder is
greatest among individuals 18-to 29-years-old (16.2%)
and lowest among individuals age 65 years and older
(1.5%).
• It decreases among adults in middle age
• The 12-month prevalence of alcohol use disorder is
estimated to be
 4.6% among 12- to 17-year-olds and
 8.5% among adults age 18 years and older
• Rates of the disorder are greater among adult men (12.4%)
than among adult women (4.9%).
• The first episode of alcohol intoxication is likely to

occur during the mid-teens.
• The age at onset of an alcohol use disorder with two or
more of the criteria clustered together peaks in the late
teens or early to mid 20s.
• The large majority of individuals who develop alcohol-
related disorders do so by their late 30s.
• An earlier onset of alcohol use disorder is observed in
adolescents with preexisting conduct problems and
those with an earlier onset of intoxication.
• Alcohol use disorder has a variable course that is
characterized by periods of remission and relapse.
• A decision to stop drinking, often in response to a
crisis, is likely to be followed by a period of weeks or
more of abstinence,
• It is often followed by limited periods of controlled or
nonproblematic drinking.
• Among adolescents, conduct disorder and repeated
antisocial behavior often co-occur with alcohol- and with
other substance-related disorders.
• Most individuals with alcohol use disorder develop the
condition before age 40 years,
• Perhaps 10% of individuals with AUD have later onset.
• Age-related physical changes in the elderly
1. increased brain susceptibility to the
depressant effects of alcohol
2. decreased rates of liver metabolism
3. decreased percentages of body water
• These changes can cause older people to develop more
severe intoxication and subsequent problems at lower
levels of consumption.
• Alcohol-related problems in older people are also
especially likely to be associated with other medical
complications.
• Environmental.
• Environmental risk and prognostic factors may include
1. cultural attitudes toward drinking and intoxication,

2. the availability of alcohol (including price),
3. acquired personal experiences with alcohol, and s
4. stress levels.
• Additional potential mediators of how alcohol problems
develop in predisposed individuals include heavier peer
• substance use, exaggerated positive expectations of the
effects of alcohol, and suboptimal ways of coping with
stress.
• Genetic and physiological. Alcohol use disorder runs in
families, with 40%-60% of the variance of risk
explained by genetic influences.
• The rate of this condition is three to four times higher in
close relatives of individuals with alcohol use disorder
• The values are highest for
1. individuals with a greater number of affected relatives,

2. closer genetic relationships to the affected person, and
3. higher severity of the alcohol-related problems in those
relatives
• A significantly higher rate of alcohol use disorders
exists in the monozygotic twin than in the dizygotic
twin of an individual with the condition.
• A three- to fourfold increase in risk has been observed
in children of individuals with alcohol use disorder
• Among the low-risk phenotypes are the acute alcohol-
related skin flush (seen most prominently in Asians)
• . High vulnerability is associated with preexisting
1. schizophrenia or
2. bipolar disorder,
3. impulsivity (producing enhanced rates of all substance
use disorders and
4. gambling disorder), and
5. a high risk specifically for alcohol use disorder is

associated with a low level of response (low
sensitivity) to alcohol.
• A number of gene variations may account for low
response to alcohol or modulate the dopamine reward
systems
• In general, high levels of impulsivity are associated with an
earlier onset and more severe alcohol use disorder
• In most cultures, alcohol is the most frequently used
intoxicating substance and contributes to considerable
morbidity and mortality.
• An estimated 3.8% of all global deaths and 4.6% of global
disability-adjusted life-years are attributable to alcohol.
• In USA 80% of adults (age 18 years and older) have
consumed alcohol at some time in their lives, and 65% are
current drinkers (last 12 months).
• Polymorphisms of genes for the alcohol-metabolizing
enzymes
1. alcohol dehydrogenase and

2. aldehyde dehydrogenase
are most often seen in Asians and affect the response to
alcohol disorder.
• When consuming alcohol, individuals with these gene
variations can experience a flushed face and
palpitations, reactions that can be so severe as to limit or
preclude future
alcohol consumption and diminish the risk for alcohol use
• These gene variations are seen in as many as 40% of
Japanese, Chinese, Korean, and related groups
worldwide and are related to lower risks for the disorder.
Gender-Related Diagnostic issues

• Males have higher rates of drinking and related
disorders than females.
• Females generally
1. Weigh less than males,
2. They have more fat and less water in their bodies,

3. metabolize less alcohol in their esophagus and
stomach,
4. they are likely to develop higher blood alcohol levels
per drink than males.
6. Females who drink heavily may also be more
vulnerable than males to some of the physical
consequences associated with alcohol, including liver
disease.
• Diagnostic Markers
• Heavier drinking places individuals at elevated risk for
alcohol use disorder can be identified both through
standardized questionnaires and by elevations in blood
• These measures do not establish a diagnosis of an alcohol-
related disorder but can be useful in highlighting
individuals for whom more information should be
gathered.
• The most direct test available to measure alcohol
consumption cross-sectionally is blood alcohol
concentration, which can also be used to judge tolerance
to alcohol.
• For example, an individual with a concentration of 150 mg
of ethanol per deciliter (dL) of blood who does not show
signs of intoxication can be presumed to have acquired at
least some degree of tolerance to alcohol.
• At 200 mg/dL, most nontolerant individuals demonstrate
severe intoxication.
• Laboratory tests
1. one sensitive laboratory indicator of heavy drinking is a
modest elevation or high-normal levels (>35 units) of
gamma-glutamyl transferase (GGT).
• This may be the only laboratory finding.
• At least 70% of individuals with a high GGT level are
persistent heavy drinkers (i.e., consuming eight or more
drinks daily on a regular basis).
2. A second test with comparable or even higher levels of
sensitivity and specificity is carbohydrate- deficient
transferrin (CDT), with levels of 20 units or higher
useful in identifying individuals who regularly consume
eight or more drinks daily.
 Both GGT and CDT levels return toward normal within
days to weeks of stopping drinking,
3. So, both state markers may be useful in monitoring
abstinence
4. The combination of tests for CDT and GGT may have
even higher levels of sensitivity and specificity than
either test used alone.
5. Additional useful tests include the mean corpuscular
volume (MCV)
• It may be elevated to high normal values in individuals
who drink heavily—a change that is due to the direct
toxic effects of alcohol on erythropoiesis.
Although the MCV can be used to help identify those
who drink heavily, it is a poor method of monitoring
abstinence because of the long half-life of red blood
cells.
5. Liver function tests (e.g., alanine aminotransferase

[ALT] and alkaline phosphatase) can reveal liver injury
that is a consequence of heavy drinking.
• Other potential markers of heavy drinking that are more
nonspecific for alcohol but can help the clinician think
of the possible effects of alcohol include elevations in
blood levels of lipids (e.g., triglycerides and high-
density lipoprotein cholesterol) and high-normal levels
of uric acid.
• Additional diagnostic markers relate to signs and
symptoms that reflect the consequences often associated
with persistent heavy drinking.
• For example, dyspepsia, nausea, and bloating can
accompany gastritis, and hepatomegaly, esophageal
varices, and hemorrhoids may reflect alcohol-induced
changes in the liver.
• Other physical signs of heavy drinking include tremor,
• Males with chronic alcohol use disorder may exhibit
decreased testicular size and feminizing effects
associated with reduced testosterone levels.
• Repeated heavy drinking in females is associated with
menstrual irregularities and, during pregnancy,
spontaneous abortion and fetal alcohol syndrome.
• Individuals with preexisting histories of epilepsy or
severe head trauma are more likely to develop alcohol-
• Alcohol withdrawal may be associated with nausea,
vomiting, gastritis, hematemesis, dry mouth, puffy blotchy
complexion, and mild peripheral edema.
• Functional Consequences of Alcohol Use
Disorder
• The diagnostic features of alcohol use disorder
highlighting major areas of life functioning:
• These include
1. driving and
2. operating machinery,
3. school and work,
4. interpersonal relationships and
5. communication, and
6. health.
• Alcohol-related disorders contribute to
1. absenteeism from work,
2. job-related accidents, and

3. low employee productivity.
• Rates are elevated in homeless individuals, perhaps
reflecting a downward spiral in social and
occupational functioning,
• However, most individuals with alcohol use disorder
continue to live with their families and function
within their jobs.
• Alcohol use disorder is associated with a significant
increase in the risk of accidents, violence, and suicide.
• It is estimated that one in five intensive care unit
admissions in some urban hospitals is related to alcohol
• 40% of individuals in the United States experience an
alcohol-related adverse event at some time in their lives,
• Alcohol accounting for up to 55% of fatal driving events.
• Severe alcohol use disorder, especially in individuals with

antisocial personality disorder, is associated with the
commission of criminal acts, including homicide.
• Severe problematic alcohol use also contributes to
disinhibition and feelings of sadness and irritability,
which contribute to suicide attempts and completed
suicides.
• Differential Diagnosis
1. Nonpathological use of alcohol.
• The key element of alcohol use disorder: the use of heavy
doses of alcohol with resulting repeated and significant
distress or impaired functioning.
• Most drinkers sometimes consume enough alcohol to
feel intoxicated,
• Only a minority (less than 20%) ever develop alcohol
use disorder.
• Therefore, drinking, even daily, in low doses and
occasional intoxication do not by themselves make this
diagnosis.
• Sedative, hypnotic, or anxiolytic use disorder.
• The signs and symptoms of alcohol use disorder are
similar to those seen in sedative, hypnotic, or anxiolytic
use disorder
• The two must be distinguished because the course
may be different, especially in relation to medical
problems.
• Conduct disorder in childhood and adult
antisocial personality disorder
• The majority of individuals with adult antisocial
personality and preexisting conduct disorder have
alcohol use disorder, along with other substance use
disorders,
• These diagnoses are associated with an early onset of
alcohol use disorder as well as a worse prognosis, it is
important to establish both conditions
1. Bipolar disorders,
2. schizophrenia, and The rate is makedly
3. antisocial personality disorderer rincreased

• The rate is increased in several anxiety and depressive
disorders in persons with alcohol use disorder as well
• Severe, repeated alcohol intoxication may also suppress
immune mechanisms and predispose individuals to
infections and increase the risk for cancers
Alcohol Intoxication
A. Recent ingestion of alcohol.
B. Clinically significant problematic beliavioral or

psychological changes (e.g., inappropriate sexual or
aggressive behavior, mood lability, impaired
judgment) that developed during, or shortly after,
alcohol ingestion.
C. One (or more) of the following signs or symptoms
developing during, or shortly after,
• alcohol use:
1. Slurred speech.
2. Incoordination.
3. Unsteady gait.
4. Nystagmus.
5. Impairment in attention or memory.
6. Stupor or coma.
D. The signs or symptoms are not attributable to
explained by another mental disorder,
including intoxication with another substance
Standard drink is approximately 10-12 grams

of ethanol
• Associated Features Supporting Diagnosis
• Blackouts (Amnesia are associated with memory lapses for
the events that occurred during the course of the alcohol
intoxication.
• Blackouts may be related to the presence of a high blood
alcohol level and, perhaps, to the rapidity with which this
level is reached.
• During even mild alcohol intoxication, different symptoms
are likely to be observed at different time points.
• Evidence of mild intoxication with alcohol
• Seen in most individuals after approximately two drinks
raising the blood alcohol concentration approximately
by 20 mg/ dL.
• Early signs and symptoms of intoxication often include
1. talkativeness,
2. a sensation of well-being, and
3. a bright, expansive mood.

• Later, especially when blood alcohol levels are falling, the
individual is likely to become
 progressively more depressed,
 withdrawn, and
 cognitively impaired.
• At very high blood alcohol levels (e.g., 200-300 mg/dL), an

individual who has not developed tolerance for alcohol is
likely to fall asleep and enter a first stage of anesthesia.
• Higher blood alcohol levels (e.g., in excess of 300-400
mg/dL) can cause inhibition of
1. Respiration
2. pulse and
3. even death
in nontolerant individuals.
• The duration of intoxication depends on how much
alcohol was consumed over what period of time.
• In general, the body is able to metabolize
approximately one drink per hour, so that the blood

alcohol level generally decreases at a rate of 15-20
mg/dL per hour.
• Signs and symptoms of intoxication are likely to be
more intense when the blood alcohol level is rising
than when it is falling.
• Alcohol intoxication is an important contributor to
suicidal behavior.
• There appears to be an increased rate of suicidal
behavior, as well as of completed suicide, among
persons intoxicated by alcohol.
• Prevalence
• The large majority of alcohol consumers are likely to
have been intoxicated to some degree at some point in
their lives.
• For example, in 2010, 44% of 12th-grade students
admitted to having been "drunk in the past year," with
more than 70% of college students reporting the same.
• Intoxication usually occurs as an episode usually
developing over minutes to hours and typically lasting
several hours.
• The average age at first intoxication is approximately
15 years, with the highest prevalence at approximately
18-25 years.
• Frequency and intensity usually decrease with further
advancing age.
• The earlier the onset of regular intoxication, the
greater the likelihood the individual will go on to
develop alcohol use disorder.
• Risk and Prognostic Factors
• Temperamental.
• Episodes of alcohol intoxication increase with
personality characteristics of sensation seeking and
impulsivity.
• Environmental.
• Episodes of alcohol intoxication increase with a heavy
drinking environment.
• Temperamental.
impulsivity.
• Environmental.
• Temperamental.
impulsivity.
• Environmental.
• Culture-Related Diagnostic issues
• Intoxication s usually established by observing
1. an individual's behavior and

2. smelling alcohol on the breath.
• The degree of intoxication increases with
1. an individual's blood or
2. breath alcohol level and
3. with the ingestion of other substances, (those with

sedating effects)
• Diagnostic Markers
• Intoxication is usually established by observing
1. an individual's behavior
2. smelling alcohol on the breath.

3. breath alcohol
4. level and with the ingestion of other substances,
those with sedating effects.
5. Blood alcohol
• Functional Consequences of Alcohol intoxication
Alcohol intoxication contributes to the more than

30,000 alcohol-related drinking deaths in each year.
 In addition, intoxication with this drug contributes to
huge costs associated
1. with drunk driving,
2. lost time from school or work, and
3. interpersonal arguments,
4. physical fights.
• Gender-Related Diagnostic Issues
• In many Western societies, acceptance of drinking
and drunkenness is more tolerated for males,
• such gender differences may be much less
prominent in recent years, especially during
adolescence and young adulthood.
A. Other medical conditions. Several medical (e.g.,
diabetic acidosis) and neurological conditions
• (e.g., cerebellar ataxia, multiple sclerosis) can
temporarily resemble alcohol intoxication.
B. Sedative, hypnotic, or anxiolytic intoxication.
Intoxication with sedative, hypnotic, or
• anxiolytic drugs or with other sedating substances
(e.g., antihistamines, anticholinergic drugs) can be
mistaken for alcohol intoxication.
• The differential requires observing
1. Alcohol on the breath,
2. measuring blood or
3. measuring breath alcohol levels,
4. ordering a medical workup, and
5. gathering a good history.
• The signs and symptoms of sedative-hypnotic
intoxication are very similar to those observed with
alcohol and include similar problematic behavioral
• or psychological changes.
• These changes are accompanied by evidence of
impaired functioning and judgment
• if it is intense it can result in a life-threatening
coma, and levels of incoordination that can interfere
with driving abilities and with performing usual
• activities.
• However, there is no smell as there is with alcohol,
but there is likely to be evidence of misuse of the
depressant drug in the blood or urine toxicology
analyses.
Comorbidity
• Alcohol intoxication may occur comorbidly with
other substance intoxication, especially
• in individuals with conduct disorder or antisocial
personality disorder.
• Alcohol Withdrawal
• 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 the cessation of
(or reduction in) alcohol use described in Criterion
A:
• 1. Autonomic hyperactivity (e.g., sweating or pulse
rate greater than 100 pm).
• 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. Generalized tonic-clonic seizures.

C. The signs or symptoms in Criterion B cause
clinically significant distress or impairment in
social, occupational, or other important areas of
functioning.
D. The signs or symptoms are not attributable to
explained by another mental disorder, including
intoxication or withdrawal from another
• Specify if:
• With perceptual disturbances: This specifier applies
in the rare instance when hallucinations usually
visual or tactile occur with intact reality testing, or
auditory, visual, or tactile illusions occur in the
absence of a delirium.
• Diagnostic Features
• The essential feature of alcohol withdrawal is the
presence of a characteristic withdrawal syndrome
that develops within several hours to a few days
after the cessation of (or reduction
• in) heavy and prolonged alcohol use (Criteria A and
B). The withdrawal syndrome
• includes two or more of the symptoms reflecting
autonomic hyperactivity and anxiety listed in
Criterion B, along with gastrointestinal symptoms.
Associated Features Supporting Diagnosis
• Confusion and changes in consciousness are not
core criteria for alcohol withdrawal
• Nevertheless, alcohol withdrawal delirium may
occur in the context of withdrawal.
• As is true for any agitated, confused state, in
addition to a disturbance of consciousness and
cognition, withdrawal delirium can include visual,
tactile, or (rarely) auditory hallucinations (delirium
tremens).
• When alcohol withdrawal delirium develops, it is
likely that a clinically relevant medical condition
may be present:
 liver failure,
 pneumonia,
 gastrointestinal bleeding,
 sequelae of head trauma,
 hypoglycemia,
 an electrolyte imbalance,
 postoperative status.
Prevalence
• It is estimated that approximately 50% of middle-
class, highly functional individuals with alcohol use
disorder have ever experienced a full alcohol
withdrawal syndrome.
• Among individuals with alcohol use disorder who
are hospitalized or homeless, the rate of alcohol
withdrawal may be greater than 80%.
• Less than 10% of individuals in withdrawal ever
demonstrate alcohol withdrawal delirium or
withdrawal seizures.
• Acute alcohol withdrawal occurs as an episode
usually lasting 4-5 days and only after extended
periods of heavy drinking.
• Withdrawal is relatively rare in individuals
younger than 30 years, and the risk and severity
increase with increasing age.
Community Based Organizations
• Cannabis-Related Disorders
1. Cannabis Use Disorder
2. Cannabis Intoxication
3. Cannabis Withdrawal
4. Other Cannabis-Induced Disorders

Cannabis-Related Disorders
• Cannabis Use Disorder
A. A problematic pattern of cannabis use leading to
clinically significant impairment or distress, as
manifested by at least two of the following, occurring
within a 12-month period:
1. Cannabis 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 cannabis use.
3. A great deal of time is spent in activities necessary to
obtain cannabis, use cannabis,
or recover from its effects.
4. Craving, or a strong desire or urge to use cannabis.

5. Recurrent cannabis use resulting in a failure
to fulfill major role obligations at work,
school, or home.
6. Continued cannabis use despite having

persistent or recurrent social or interpersonal
problems caused or exacerbated by the
effects of cannabis.
7. Important social, occupational, or recreational
activities are given up or reduced because of cannabis
use.
8. Recurrent cannabis use in situations in which it is
physically hazardous.
9. Cannabis 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 cannabis.
10. Tolerance, as defined by either of the following:
11. a. A need for markedly increased amounts of
cannabis to achieve intoxication or desired effect.
b. Markedly diminished effect with continued use of the
same amount of cannabis.
11. Withdrawal, as manifested by either of the following:
• a. The characteristic withdrawal syndrome for cannabis
b. Cannabis (or a closely related substance) is taken to relieve
or avoid withdrawal symptoms.
• In early remission: After full criteria for cannabis use
disorder were previously met, none of the criteria for
cannabis use disorder have been met for at least 3
months but for less than 12 months (with the exception
that Criterion A4, “Craving, or a strong desire or urge to
use cannabis,” may be met).
• In sustained remission; After full criteria for cannabis
use disorder were previously met, none of the criteria
for cannabis use disorder have been met at any time
during a period of 12 months or longer (with the
exception that Criterion A4, “Craving, or a strong desire
or urge to use cannabis,” may be present).
• Specify if:
• In a controlled environment: This additional specifier

is used if the individual is in an environment where
access to cannabis is restricted.
• Diagnostic Features
• Cannabis use disorder and other cannabis-related
disorders include problems that are associated with
substances derived from the cannabis plant and
chemically similar synthetic compounds.
• The plant material has many names
weed mary gangster
pot, jane kif,
herb, dagga ganja
grass bhang
reefer skunk
dope boom
• A concentrated extraction of the cannabis plant that
is also commonly used is hashish.
• Cannabis is the generic and perhaps the most
appropriate scientific term for the sychoactive
substance(s) derived from the plant
Community Assessment - Change
• What are key issues that people are
struggling with
• What motivates change?
• What are the strategies that effect change?
Assessing Problems of Addiction
• Substance abuse and addiction is a problem that confronts
the individual who suffers from it, and it also impacts the
family, the economy, the health care system and society.
• Addicts are often in denial
• Typically, people who have an addiction, have multiple
relapses, sometimes over a period of many years, before
they are “cured”
• Often the addict is in a relationship with someone who
enables the addiction.
• There is often a family history of addiction or substance
abuse (nature-nurture)
Assessing Problems of Addiction II
• Get detailed history, i.e. what substances are
used, how, when.
• Does the patient agree that substance use is
a problem. If not, who does?
• Does the patient’s use of substances
constitute a medical or psychiatric risk?
Assessing Problems of Addiction III
• Confronting denial in the patient
• Confronting countertransference in you
• Identifying resources
• Meet the patient where the patient is at.
• Identify and include family, friends, support
network as part of overall treatment plan.
Assessing Mental Illness
• Mental Status Examination
• History of Illness
• Family History
• Treatment History
• Impact of Illness on the individual
• Impact of Illness on the family
• Impact of Illness on the community
Assessing Problems of Chronic
Illness
• Date of onset
• Course of illness
• Reaction of patient to illness
• Reaction of family and/or caregiver
• Current level of function
• Coping mechanisms
• Strengths
Assessing Problems of Illness II
• Common challenges
• Impact on quality of life
• Psychological impact
• Impact on family and social network
HIV/AIDS
• Living with a stigmatizing illness
• Navigating disclosure
• Sexuality
• Managing medications
• Uncertainty vs. Hope
Considerations re: HIV/AIDS
• External challenges
• Compliance
• Community intervention and support
Assessing Problems of DV
• DV is a public health problem
• Cuts across race, ethnicity, and social class
• Involves the gamut (A complete extent or
range )of helping professionals
Indicators of DV – physical
findings
• Any injury to face, head, neck throat, chest
abdomen, genital areas, dental trauma,
burns and sexual assault.
• Chronic abdominal, pelvic or chest pain
• Chronic unexplained pain
• Chronic gynelogical conditions
• Headaches, migraines,chronic fatigue
• Non compliance with medical treatment
DV – Common Characteristics
• Defensive injuries of forearms
• Injuries that are not explained well
• Injuries to multiple areas
• Any injury that might result from sexual
assault
• Unexplained stroke in a young woman
DV – Behavioral Indicators
• Delay in seeking treatment
• Injury inconsistent with explanation given
• Repeated use of ER services
• Partner answers questions for patient or
insists on being present when asked to leave
room
• Overly attentive or verbally abusive partner
DV – Risk Assessment
• Understanding risk helps with safety
planning and intervention
• Knowledge of history of DV
• Understanding of abuser’s behavior and
context of abuse
• How would intervention increase risk?
DV – Risk Indicators
• Abuser presents with SI/HI, attempts or threats
• Has weapons or easy access to them
• Substance abuse
• Criminal history
• Training in martial arts and/or military
• Specific or non-specific threats to harm
• Past or present use of physical or sexual
violence
DV- Risk Indicators II
• Stalking
• Psychiatric Diagnosis
• Abuse of children or other family members
or threats to harm them
• Recent investigation by law enforcement
• Victim is planning to leave
DV- Safety Planning
• Develop a safety plan
• Provide information: about resources,
victim’s rights
• Create support and connections
• Foster hope and empowerment
Obstacles to Care
• Hard to treat, difficult, resistant patients
• Resistance: in the individual, in the family and in the
treater
• Beliefs and Values:
– Patient
– Family
– Community
– Treater
Strategies
• Working with Resistance
• Using leverage(power to act effectively)
• Setting limits
• Expectations
• Utilizing Resources
SW – Contribution to the
Community
• Part of multi-disciplinary team
• Involved with community agencies
• Help create beneficial programs
Beneficial Programs
• Eleanor Robbins Community Program:
Caring For Each Other
• Camp Wee-Kan-Tu
Eleanor Robbins Program
• A community service program for high
school students
• An opportunity for patients with AD
• A research pilot
• Co-founded by Stanley L. Robbins, Eileen
Salmanson
• Directed by Jeffrey Robbins
Camp Wee-Kan-Tu
• The first overnight summer camp for
children with epilepsy
• Co-Founders – Jeff Robbins and Eileen
Salmanson
• Collaboration with EFMRI
• Funded through donations
• Started as an idea, now in its 13th summer.
Evaluation and Review
• Genogram of the family
• What are the issues that most significantly
impact this family?
• Who might be in need of services and why?
• What services would be recommended?
• How would you assess this, and what
obstacles, if any, would you anticipate in
working with this family?

Substance-Related Disorders

Uploaded by

Copyright:

Available Formats

Substance-Related Disorders

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Substance-Related Disorders

Uploaded by

Copyright:

Available Formats

Substance Related Disorders

• Alemayehu Negash, MD, PhD,

All drugs that are taken in excess have in common

Nicotine, phencyclidine [PCP],

Drugs typically activate the reward system and

Such Individuals can be particularly at risk to

Two broad categories:

1. Substance use disorders

2. Substance Induced Disorders

ii. bipolar and related disorders,

v. obsessive-compulsive and related disorders,

vii. sexual dysfunctions,

ix. neurocognitive disorders

These cluster of symptoms must indicate that the

Criterion 10: Tolerance is signaled by requiring

1. a past history of withdrawal

2. an earlier onset of a substance use disorder,

are associated with a more severe clinical course

• A general estimate of severity

2. Moderate: four to five symptoms, and

3. Severe: six or more symptoms.

2. report of knowledgeable others,

3. on maintenance therapy, and

• In general, the longer the acute withdrawal period, the

• Development and Course

• They develop in the context of the effects of substances of

B. There is evidence from the history, physical examination, or

Such evidence of an independent mental disorder includes the

withdrawal or exposure to the medication; or

3. steroid drugs, as well as during

4. any prescription or over-the-counter depressant or

2. medication-induced mental disorders, or

1. cessation of acute withdrawal,

3. use of the medication.

• . Most other substance/medication-induced mental

1. cessation of acute withdrawal,

3. use of the medication.

more than 1 month after complete cessation of

2. There is a persistent desire or unsuccessful efforts to cut

4. Craving, or a strong desire or urge to use alcohol.

7. Important social, occupational, or recreational activities

• The first episode of alcohol intoxication is likely to

1. cultural attitudes toward drinking and intoxication,

1. individuals with a greater number of affected relatives,

5. a high risk specifically for alcohol use disorder is

1. alcohol dehydrogenase and

Gender-Related Diagnostic issues

1. Weigh less than males,

2. They have more fat and less water in their bodies,

5. Liver function tests (e.g., alanine aminotransferase

1. absenteeism from work,

2. job-related accidents, and

• Severe alcohol use disorder, especially in individuals with

2. schizophrenia, and The rate is makedly

3. antisocial personality disorderer rincreased

B. Clinically significant problematic beliavioral or

Standard drink is approximately 10-12 grams

• Early signs and symptoms of intoxication often include