Substance Use Disorder

Main Features
• The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and
physiological symptoms indicating that the individual continues using the substance despite
significant substance-related problems.
• The diagnosis of a substance use disorder can be applied to all 10 classes included except
caffeine.
• For certain classes some symptoms are less salient, and in a few instances not all symptoms
apply (e.g., 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 that may persist beyond detoxification, particularly in individuals with severe 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
ROUTES OF ADMINISTRATION
Depressants
• Depressants slow the activity of the central nervous system.
• They reduce tension and inhibitions and may interfere with a person’s
judgment, motor activity, and concentration.
• The three most widely used groups of depressants are
• alcohol,
• sedative-hypnotic drugs,
• and opioids.
Alcohol-Related Disorders
• 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:
Impaired Control
• 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 recovôr from its effects.
• 4. Craving, or a strong desire or urge to use alcohol.
• Craving for alcohol is indicated by a strong desire to drink that makes it difficult to think
of anything else and that often results in the onset of drinking
.
Social Impairment
• 5. Recurrent alcohol use resulting in a failure to fulfill major role
obligations at work, school, or home.
• School and job performance may also suffer either from the aftereffects of
drinking or from actual intoxication at school or on the job;
• child care or household responsibilities may be neglected;
• and alcohol-related absences may occur from school or work.
• 6. Continued alcohol use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of alcohol.
• Finally, individuals with an alcohol use disorder may continue to consume alcohol
despite the knowledge that continued consumption poses significant physical (e.g.,
blackouts, liver disease), psychological (e.g., depression), social, or interpersonal
problems (e.g., violent arguments with spouse while intoxicated, child abuse).

• 7. Important social, occupational, or recreational activities are given up or reduced

because of alcohol use.
Risky use of the substance
• 8. Recurrent alcohol use in situations in which it is physically hazardous.
• The individual may use alcohol in physically hazardous circumstances (e.g., driving an automobile,
swimming, operating machinery while intoxicated).
• 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.
Pharmacological Criteria
• 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 (refer to Criteria A and B of the criteria set for alcohol
withdrawal, pp. 499-500).
• b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal
symptoms
• Alcohol withdrawal is characterized by withdrawal symptoms that develop approximately 4-12 hours after the reduction of
intake following prolonged, heavy alcohol ingestion. Because withdrawal from alcohol can be unpleasant and intense,
individuals may continue to consume alcohol despite adverse consequences, often to avoid or to relieve withdrawal symptoms.
Some withdrawal symptoms (e.g., sleep problems) can persist at lower intensities for months and can contribute to relapse.
Once a pattern of repetitive and intense use develops, individuals with alcohol use disorder may devote substantial periods of
time to obtaining and consuming alcoholic beverages.
Specifiers
• In early remission: After full criteria for alcohol use disorder were
previously met, none of the criteria for alcohol 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 alcohol,” may be met).
• In sustained remission: After full criteria for alcohol use disorder
were previously met, none of the criteria for alcohol 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 alcohol,” may be met).
• It is also important to consider the question: What counts as a drink? A 12-ounce
glass of beer, a 5-ounce glass of wine, and 1.5 ounces of “hard liquor” (like a shot
of tequila) are all considered one drink.
• The size of the drink is not what matters. Rather, it is the alcohol content of
the beverage.
• Alcohol produces its effects through its interactions with several
neurotransmitters.
• It stimulates gamma-aminobutyric acid (GABA) receptors, which may
account for its ability to reduce tension. (GABA is a major inhibitory
neurotransmitter; the benzodiazepines, such as Xanax, have an eff ect on GABA
receptors similar to that of alcohol.)
• Alcohol also increases levels of serotonin and dopamine, which may be the
source of its ability to produce pleasurable effects.
• Finally, alcohol inhibits glutamate receptors, which may cause the cognitive eff
ects of alcohol intoxication, such as slowed thinking and memory loss.
Alcohol Intoxication
• A. Recent ingestion of alcohol.
• B. Clinically significant problematic behavioral 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.
• trouble speaking, your words are slow or garbled, or your words run together.
• 2. Incoordination.
• lack of coordination especially of muscular movements resulting from loss of voluntary control.
• 3. Unsteady gait.
• 4. Nystagmus.
• the eyes make repetitive, uncontrolled movements. These movements often result in reduced vision and depth perception and can
affect balance and coordination. These involuntary eye movements can occur from side to side, up and down, or in a circular
pattern.
• 5. Impairment in attention or memory.
• 6. Stupor or coma.
• Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will
immediately lapse back to the unresponsive state.
• Coma is a state of unarousable unresponsiveness
• D. The signs or symptoms are not attributable to another medical condition and are not better
explained by another mental disorder, including intoxication with another substance.
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 bpm).
• 2. Increased hand tremor.
• 3. Insomnia.
• 4. Nausea or vomiting.
• 5. Transient visual, tactile, or auditory hallucinations or illusions.
• 6. Psychomotor agitation.
• increased psychomotor activity, motor restlessness, and irritability
• 7. Anxiety.
• 8. Generalized tonic-clonic seizures
• A generalized tonic-clonic seizure, formerly known as grand mal seizure, is defined as a seizure that has a tonic
phase followed by clonic muscle contractions.
• 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 another medical condition and are not
better explained by another mental disorder, including intoxication or withdrawal from
• The withdrawal symptoms typically begin when blood concentrations of
alcohol decline sharply (i.e., within 4-12 hours) after alcohol use has been
stopped or reduced.
• Reflecting the relatively fast metabolism of alcohol, symptoms of alcohol
withdrawal usually peak in intensity during the second day of
abstinence and are likely to improve markedly by the fourth or fifth day.
• Following acute withdrawal, however, symptoms of anxiety, insomnia, and
autonomic dysfunction may persist for up to 3-6 months at lower levels of
intensity.
• Fewer than 10% of individuals who develop alcohol withdrawal will ever
develop dramatic symptoms (e.g., severe autonomic hyperactivity, tremors,
alcohol withdrawal delirium).
• Tonic-clonic seizures occur in fewer than 3% of individuals.
Opioid Use Disorder
See Criteria from DSM-5
• Similar to all Use disorders
 Features
• Opioid use disorder includes signs and symptoms that reflect compulsive,
prolonged self-administration of opioid substances that are used for no
legitimate medical purpose or, if another medical condition is present that
requires opioid treatment, that are used in doses greatly in excess of the
amount needed for that medical condition.
• For example, an individual prescribed analgesic opioids for pain relief at
adequate dosing will use significantly more than prescribed and not only
because of persistent pain.
• Individuals with opioid use disorder tend to develop such regular patterns of
compulsive drug use that daily activities are planned around obtaining
and administering opioids.
• Opioids are usually purchased on the illegal market but may also be obtained
from physicians by falsifying or exaggerating general medical problems or
by receiving simultaneous prescriptions from several physicians.
• Health care professionals with opioid use disorder will often obtain opioids
by writing prescriptions for themselves or by diverting opioids that have
been prescribed for patients or from pharmacy supplies.
• Most individuals with opioid use disorder have significant levels of tolerance
and will experience withdrawal on abrupt discontinuation of opioid
substances.
• Individuals with opioid use disorder often develop conditioned responses to
drug-related stimuli (e.g., craving on seeing any heroin powder-like
substance)—a phenomenon that occurs with most drugs that cause intense
psychological changes.
• These responses probably contribute to relapse, are difficult to extinguish,
and typically persist long after detoxification is completed
• Opioids are a class of drugs that derive from, or mimic, natural
substances found in the opium poppy plant. Opioids work in the brain
to produce a variety of effects, including pain relief
Opioid Intoxication
• A. Recent use of an opioid.
• B. Clinically significant problematic behavioral or psychological changes (e.g.,
initial euphoria followed by apathy, dysphoria, psychomotor agitation or
retardation, impaired judgment) that developed during, or shortly after, opioid
use.
• C. Pupillary constriction (or pupillary dilation due to anoxia* from severe
overdose) and one (or more) of the following signs or symptoms developing
during, or shortly after, opioid use:
• 1. Drowsiness (feeling of being sleepy and lethargic; sleepiness) or coma.
• 2. Slurred speech.
• 3. Impairment in attention or memory.
• D. The signs or symptoms are not attributable to another medical condition and
are not better explained by another mental disorder, including intoxication with
another substance.
• Individuals with opioid intoxication may demonstrate inattention to the environment,
even to the point of ignoring potentially harmful events
Opioid Withdrawal
• A. Presence of either of the following;
• 1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e., several
weeks or longer).
• 2. Administration of an opioid antagonist after a period of opioid use.
• B. Three (or more) of the following developing within minutes to several days after Criterion A:
• 1. Dysphoric mood.
• 2. Nausea or vomiting.
• 3. Muscle aches.
• 4. Lacrimation (the flow of tears) or rhinorrhea (excess fluid drains from the nose).
• 5. Pupillary dilation, piloerection, or sweating.
• 6. Diarrhea.
• 7. Yawning.
• 8. Fever.
• 9. Insomnia.
• 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 another medical condition and are not better
explained by another mental disorder, including intoxication or withdrawal from another
substance.
Opioids
• The opioids include opium and its derivatives: morphine, heroin, and
codeine
• Withdrawal from heroin may begin within 8 hours of the last injection
in users who have built up high tolerance.
• These symptoms typically persist for about 72 hours and then diminish
gradually over a 5- to 10-day period
 Sedative, Hypnotic, or
Anxiolytic Use Disorder
• Barbiturates: First discovered in Germany more than 100 years ago,
barbiturates were widely prescribed in the first half of the twentieth
century to fight anxiety and to help people sleep. Although still
prescribed by some physicians, these drugs have been largely replaced
by benzodiazepines, which are generally safer drugs.
• Benzodiazepines benzodiazepines, the antianxiety drugs developed in
the 1950s, as the most popular sedative-hypnotic drugs available. Xanax,
Ativan, and Valium are just three of the dozens of these compounds in
clinical use
Diagnostic Criteria for Use Disorder is same
as before
• Check out DSM-5
• Sedative, hypnotic, or anxiolytic substances include benzodiazepines,
benzodiazepinelike drugs (e.g., zolpidem, zaleplon), carbamates (e.g.,
glutethimide, meprobamate), barbiturates (e.g., secobarbital), and
barbiturate-like hypnotics (e.g., glutethimide, methaqualone).
• This class of substances includes all prescription sleeping medications and
almost all prescription antianxiety medications.
• Misuse of substances from this class may occur on its own or in conjunction
with use of other substances.
• For example, individuals may use intoxicating doses of sedatives or benzodiazepines
to "come down" from cocaine or amphetamines or use high doses of benzodiazepines
in combination with methadone to "boost" its effects.
Sedative, Hypnotic, or
Anxiolytic Intoxication
• A. Recent use of a sedative, hypnotic, or anxiolytic.
• B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual
or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after,
sedative, hypnotic, or anxiolytic use.
• C. One (or more) of the following signs or symptoms developing during, or shortly after, sedative,
hypnotic, or anxiolytic use:
• 1. Slurred speech.
• 2. Incoordination.
• at levels that can interfere with driving abilities and with performing usual activities to the point of causing falls
or automobile accidents
• 3. Unsteady gait.
• 4. Nystagmus.
• 5. Impairment in cognition (e.g., attention, memory).
• Memory impairment is a prominent feature of sedative, hypnotic, or anxiolytic intoxication and is most often
characterized by an anterograde amnesia tiiat resembles "alcoholic blackouts," which can be disturbing to the
individual
• 6. Stupor or coma.
• D. The signs or symptoms are not attributable to another medical condition and are not better
explained by another mental disorder, including intoxication with another substance.
Sedative, Hypnotic, or
Anxiolytic Withdrawal
• A. Cessation of (or reduction in) sedative, liypnotic, or anxiolytic use that has been prolonged.
• B. Two (or more) of the following, developing within several hours to a few days after the
cessation of (or reduction in) sedative, hypnotic, or anxiolytic use described in Criterion A:
• 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
• 2. 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 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 another medical condition and are not better
explained by another mental disorder, including intoxication or withdrawal from another
substance
Stimulants
• Stimulants are substances that increase the activity of the central
nervous system, resulting in increased blood pressure and heart rate,
greater alertness, and sped-up behavior and thinking.
• Among the most troublesome stimulants are cocaine and
amphetamines, whose effects on people are very similar.
• When users report different effects, it is often because they have
ingested different amounts of the drugs.
• Two other widely used and legal stimulants are caffeine and nicotine
 Cocaine
• Cocaine—the central active ingredient of the coca plant, found in South
America—is the most powerful natural stimulant now known
• The drug was first separated from the plant in 1865.
• Native people of South America, however, have chewed the leaves of the
plant since prehistoric times for the energy and alertness the drug offers.
• Processed cocaine (hydrochloride powder) is an odorless, white, fluffy
powder.
• For recreational use, it is most often snorted so that it is absorbed through the
mucous membrane of the nose. Some users prefer the more powerful effects
of injecting cocaine intravenously or smoking it in a pipe or cigarette.
• Cocaine apparently produces these effects largely by increasing
supplies of the neurotransmitter dopamine at key neurons
throughout the brain
• Excessive amounts of dopamine travel to receiving neurons
throughout the central nervous system and overstimulate them.
• In addition, cocaine appears to increase the activity of the
neurotransmitters norepinephrine and serotonin in some areas of
the brain
Amphetamines
• The amphetamines are stimulant drugs that are manufactured in the
laboratory.
• Some common examples are amphetamine (Benzedrine),
dextroamphetamine (Dexedrine), and methamphetamine (Methedrine).
• First produced in the 1930s to help treat asthma, amphetamines soon
became popular among people trying to lose weight; athletes seeking
an extra burst of energy; soldiers, truck drivers, and pilots trying to
stay awake; and students studying for exams through the night.
• Physicians now know the drugs are far too dangerous to be used so
casually, and they prescribe them much less freely.
Cocaine Use Disorder
• See criteria from DSM-5
Specify if
• Amphetamine-type substance
• Cocaine 305.70
• Other or unspecified stimulant
Stimulant Intoxication
• A. Recent use of an amphetamine-type substance, cocaine, or other stimulant. B. Clinically significant
problematic behavioral or psychological changes (e.g., euphoria or affective blunting: changes in
sociability: hypervigilance: interpersonal sensitivity: anxiety, tension, or anger; stereotyped
behaviors: impaired judgment) that developed during, or shortly after, use of a stimulant.
• C. Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant
use:
• 1. Tachycardia (increased heart rate) or bradycardia (lowered heart rate).
• 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. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias.
• 9. Confusion, seizures, dyskinesias*, dystonias (jerking or twisting), or coma.
• D. The signs or symptoms are not attributable to another medical condition and are not better
explained by another mental disorder, including intoxication with another substance.
Stimulant Withdrawal
• A. Cessation of (or reduction in) prolonged amphetamine-type substance,
cocaine, or other stimulant use.
• B. Dysphoric mood and two (or more) of the following physiological changes,
developing within a few hours to several days after Criterion A:
• 1. Fatigue.
• 2. Vivid, unpleasant dreams.
• 3. Insomnia or hypersomnia.
• 4. Increased appetite.
• 5. Psychomotor retardation or agitation.
• 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 another medical condition
and are not better explained by another mental disorder, including intoxication
or withdrawal from another substance.
Caffeine-Related Disorders
Caffeine
• Caffeine is the world’s most widely used stimulant.
• Around 80 percent of the world’s population consumes it daily.
• Most of this caffeine is taken in the form of coffee (from the coffee
bean); the rest is consumed in tea (from the tea leaf), cola (from the
kola nut), so-called energy drinks, chocolate (from the cocoa bean),
and numerous prescription and over-the-counter medications, such as
Excedrin.
 Caffeine Intoxication
• A. Recent consumption of caffeine (typically a high dose well in excess of 250 mg). B. Five (or more) of the
following signs or symptoms developing during, or shortly after, caffeine use:
• 1. Restlessness.
• 2. Nervousness.
• 3. Excitement.
• 4. Insomnia.
• 5. Flushed face (blushing).
• 6. Diuresis (excessive need to urinate).
• 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.
• 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 another medical condition and are not better explained by
another mental disorder, including intoxication with another substance.
 Caffeine Withdrawal
• A. Prolonged daily use of caffeine.
• B. Abrupt cessation of or reduction in caffeine use, followed within 24 hours by three (or
more) of the following signs or symptoms:
• 1. Headache.
• 2. Marked fatigue or drowsiness.
• 3. Dysphoric mood, depressed mood, or irritability.
• 4. Difficulty concentrating.
• 5. Flu-like symptoms (nausea, vomiting, or muscle pain/stiffness).
• 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 associated with the physiological effects of another
medical condition (e.g., migraine, viral illness) and are not better explained by another
mental disorder, including intoxication or withdrawal from another substance.
Cannabis-Related Disorders
Cannabis Use Disorder
• Criteria is same as Use Disorders discussed previously.
Cannabis Intoxication
• A. Recent use of cannabis.
• B. Clinically significant problematic 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.
• Intoxication typically begins with a ''high" feeling followed by symptoms that include euphoria with
inappropriate laughter and grandiosity, sedation, lethargy, impairment in short-term memory,
difficulty carrying out complex mental processes, impaired judgment, distorted sensory perceptions,
impaired motor performance, and the sensation that time is passing slowly.
• Occasionally, anxiety (which can be severe),dysphoria, or social withdrawal occurs.
• C. Two (or more) of the following signs or symptoms developing within 2 hours of
cannabis use:
• 1. Conjunctival injection (blood shot eyes).
• 2. Increased appetite.
• 3. Dry mouth.
• 4. Tachycardia.
• D. The signs or symptoms are not attributable to another medical condition and are not
better explained by another mental disorder, including intoxication with another substance.
Cannabis Withdrawal
• Cessation of cannabis use that has been heavy and prolonged (i.e., usually daily or almost daily use
over a period of at least a few months).
• B. Three (or more) of the following signs and symptoms develop within approximately 1 week
after Criterion A:
• 1. Irritability, anger, or aggression.
• 2. Nervousness or anxiety.
• 3. Sleep difficulty (e.g., insomnia, disturbing dreams).
• 4. Decreased appetite or weight loss.
• 5. Restlessness.
• 6. Depressed mood.
• 7. At least one of the following physical symptoms causing significant discomfort: abdominal pain,
shakiness/tremors, sweating, fever, chills, or headache.
• In addition to the symptoms in Criterion B, the following may also be observed postabstinence: fatigue,
yawning, difficulty concentrating, and rebound periods of increased appetite and hypersomnia that follow
initial periods of loss of appetite and insomnia
• 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 another medical condition and are not better
Inhalant-Related Disorders
Inhalant Use Disorder
• Same as all Use Disorders
Inhalants
• DSM-5 recognizes volatile hydrocarbon use meeting the above
diagnostic criteria as inhalant use disorder.
• Volatile hydrocarbons are toxic gases from glues, fuels, paints, and
other volatile compounds.
Inhalant Intoxication
• Recent intended or unintended short-term, high-dose exposure to inhalant substances, including volatile
hydrocarbons such as toluene or gasoline.
• B. Clinically significant problematic behavioral or psychological changes (e.g., belligerence (hostile and
aggressive), assaultiveness, apathy, impaired judgment) that developed during, or shortly after, exposure to
inhalants.
• C. Two (or more) of the following signs or symptoms developing during, or shortly after, inhalant use or
exposure:
• 1. Dizziness.
• 2. Nystagmus.
• 3. Incoordination.
• 4. Slurred speech.
• 5. Unsteady gait.
• 6. Lethargy.
• 7. Depressed reflexes.
• 8. Psychomotor retardation.
• 9. Tremor.
• 10. Generalized muscle weakness.
• 11. Blurred vision or diplopia.
• 12. Stupor or coma.
• 13. Euphoria.
• D. The signs or symptoms are not attributable to another medical condition and are not better explained by
another mental disorder, including intoxication with another substance.
Tobacco-Related Disorders
Tobacco Use Disorder
Tobacco Withdrawal
• A. Daily use of tobacco for at least several weeks.
• B. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24
hours by four (or more) of the following signs or symptoms:
• 1. Irritability, frustration, or anger.
• 2. Anxiety.
• 3. Difficulty concentrating.
• 4. Increased appetite.
• 5. Restlessness.
• 6. Depressed mood.
• 7. Insomnia.
• Symptoms are much more intense among individuals who smoke cigarettes or use smokeless tobacco than
among those who use nicotine medications.
• This difference in symptom intensity is likely due to the more rapid onset and higher levels of nicotine with
cigarette smoking
• 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 attributed to another medical condition and are not better
explained by another mental disorder, including intoxication or withdrawal from another substance.
Non-Substance-Related
Disorders
What is Gambling?
• Gambling involves risking something of value in the hopes of
obtaining something of greater value.
• In many cultures, individuals gamble on games and events, and most
do so without experiencing problems.
• However, some individuals develop substantial impairment related to
their gambling behaviors
 Gambling Disorder
• A. Persistent and recurrent problematic gambling behavior leading to clinically
significant impairment or distress, as indicated by the individual exhibiting four
(or more) of the following in a 12-month period:
• 1. Needs to gamble with increasing amounts of money in order to achieve the
desired excitement.
• 2. Is restless or irritable when attempting to cut down or stop gambling.
• 3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
• 4. Is often preoccupied with gambling (e.g., having persistent thoughts of
reliving past gambling experiences, handicapping or planning the next venture,
thinking of ways to get money with which to gamble).
• 5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious,
depressed).
• 6. After losing money gambling, often returns another day to get even
(“chasing” one’s losses).
• 7. Lies to conceal the extent of involvement with gambling.
• 8. Has jeopardized or lost a significant relationship, job, or educational or
career opportunity because of gambling.
• 9. Relies on others to provide money to relieve desperate financial situations
caused by gambling.
• B. The gambling behavior is not better explained by a manic episode.
Specifiers
• Specify if:
• Episodic: Meeting diagnostic criteria at more than one time point,
witli symptoms subsiding between periods of gambling disorder for at
least several months.
• Persistent: Experiencing continuous symptoms, to meet diagnostic
criteria for multiple years.
Etiology of Substance Use
Disorder
Genetic Predisposition
• For years breeding experiments have been conducted to see whether certain animals are
genetically predisposed to become dependent on drugs
• In several studies, for example, investigators have first identified animals that prefer alcohol to
other beverages and then mated them to one another.
• Generally, the offspring of these animals have been found also to display an unusual preference
for alcohol.
• Similarly, some research with human twins has suggested that people may inherit a predisposition
to abuse substances.
• One classic study found an alcohol abuse concordance rate of 54 percent in a group of identical
twins; that is, if one identical twin abused alcohol, the other twin also abused alcohol in 54
percent of the cases.
• In contrast, a group of fraternal twins had a concordance rate of only 28 percent
• For one thing, the parenting received by two identical twins may be more similar than that
received by two fraternal twins.
• A clearer indication that genetics may play a role in substance abuse and
dependence comes from studies of alcoholism rates in people adopted
shortly after birth
• These studies have compared adoptees whose biological parents are
dependent on alcohol with adoptees whose biological parents are not.
• By adulthood, the individuals whose biological parents are dependent on
alcohol typically show higher rates of alcohol abuse than those with
nonalcoholic biological parents.
• Molecular Genetics: Genetic linkage strategies and molecular biology
techniques provide more direct evidence in support of a genetic explanation
• One line of investigation has found an abnormal form of the so-called
dopamine-2 (D2) receptor gene in a majority of research participants with
alcohol, opioid, nicotine, or cocaine dependence but in less than 20 percent
of nondependent participants (
 Biochemical Factors
• Over the past few decades, researchers have pieced together several biological explanations of drug
tolerance and withdrawal symptoms
• According to one of the leading explanations, when a particular drug is ingested, it increases the
activity of certain neurotransmitters whose normal purpose is to calm, reduce pain, lift mood, or
increase alertness.
• How Tolerance Develops? When a person keeps on taking the drug, the brain apparently makes an
adjustment and reduces its own production of the neurotransmitters.
• Because the drug is increasing neurotransmitter activity or efficiency, release of the neurotransmitter
by the brain is less necessary. As drug intake increases, the body’s production of the neurotransmitters
continues to decrease, leaving the person in need of more and more of the drug to achieve its effects.
• In this way, drug takers build tolerance for a drug, becoming more and more reliant on it rather than on
their own biological processes to feel comfortable, happy, or alert.
• If they suddenly stop taking the drug, their natural supply of neurotransmitters will be low for a
time, producing the symptoms of withdrawal. Withdrawal continues until the brain resumes its normal
production of the neurotransmitters.
Which neurotransmitters are affected depends
on the drug used.
• Repeated and excessive use of alcohol or benzodiazepines may lower
the brain’s production of the neurotransmitter GABA,
• regular use of opioids may reduce the brain’s production of endorphins,
• and regular use of cocaine or amphetamines may lower the brain’s
production of dopamine
• In addition, researchers have identified a neurotransmitter called
anandamide excessive use of marijuana may reduce the production of
this neurotransmitter
• This theory helps explain why people who regularly take substances
experience tolerance and withdrawal reactions.
But why are drugs so rewarding, and why do certain people turn
to them in the first place?

• A number of brain-imaging studies suggest that many, perhaps all, drugs

eventually activate a reward center, or “pleasure pathway,” in the brain
• This reward center apparently extends from the brain area called the ventral
tegmental area (in the midbrain) to an area known as the nucleus accumbens
and on to the frontal cortex
• A key neurotransmitter in this pleasure pathway appears to be dopamine
• When dopamine is activated along the pleasure pathway, a person experiences
pleasure.
• Music may activate dopamine in the reward center. So may a hug or a word of
praise. And so do drugs. Some researchers believe that other neurotransmitters
may also play important roles in the reward center.
• Certain drugs apparently stimulate the reward center directly.
• Remember that cocaine, amphetamines, and caffeine directly increase dopa­
mine activity.
• Other drugs seem to stimulate it in roundabout ways.
• The biochemical reactions triggered by alcohol, opioids, and marijuana
probably set in motion a series of chemical events that eventually lead to
increased dopamine activity in the reward center.
• A number of theorists further believe that when substances repeatedly stimulate
this reward center, the center develops a hypersensitivity to the substances.
• Neurons in the center fire more readily when stimulated by the substances,
contributing to future desires for them.
• This theory, called the incentive-sensitization theory of addiction, has received considerable support in
animal studies
• Investigators have proposed a neurobiological theory to explain cravings, referred to as
• Craving or wanting a substance is an important component of substance use disorders.
• This theory considers both the craving (“wanting”) for drugs and the pleasure that comes with taking the
drug (“liking”)
• According to this theory, the dopamine system linked to pleasure, or liking, becomes supersensitive not
just to the direct eff ects of drugs but also to the cues associated with drugs (e.g., needles, spoons,
rolling paper).
• This sensitivity to cues induces craving, or wanting, and people go to extreme lengths to seek out and
obtain drugs.
• Over time, the liking for drugs decreases, but the wanting remains very intense. These investigators argue
that the transition from liking to powerful wanting, accomplished by the drug’s eff ects on brain pathways
involving dopamine, is what maintains the addiction
• Still other theorists suspect that people who abuse drugs may suffer from a reward-deficiency syndrome:
• Their reward center is not readily activated by the usual events in their lives, so they turn to drugs to
stimulate this pleasure pathway, particularly in times of stress.
• Abnormal genes, such as the abnormal D2 receptor gene, have been cited as a possible cause of this
syndrome
 Psychodynamic Views
• Psychodynamic theorists believe that people who abuse substances have
powerful dependency needs that can be traced to their early years
• They claim that when parents fail to satisfy a young child’s need for
nurturance, the child is likely to grow up depending excessively on others
for help and comfort, trying to find the nurturance that was lacking
during the early years.
• If this search for outside support includes experimentation with a drug, the
person may well develop a dependent relationship with the substance.
• Some psychodynamic theorists also believe that certain people respond to
their early deprivations by developing a substance abuse personality that
leaves them particularly prone to drug abuse.
 Substance Abuse Personality?
• Personality inventories, patient interviews, and even animal studies have in fact indicated that
individuals who abuse or depend on drugs tend to be more dependent, antisocial, impulsive, novelty-
seeking, and depressive than other individuals
• However, these findings are correlational (at least, the findings from human studies), and do not clarify
whether such traits lead to drug use or whether drug use causes individuals to be dependent, impulsive,
and the like.
• In an effort to establish clearer causation, one longitudinal study measured the personality traits of a
large group of nonalcoholic young men and then kept track of each man’s development
• Years later, the traits of the men who developed alcohol problems in middle age were compared
with the traits of those who did not.
• The men who developed alcohol problems had been more impulsive as teenagers and continued to
be so in middle age, a finding suggesting that impulsive men are indeed more prone to develop alcohol
problems.
• Some people with a drug addiction appear to be dependent, others impulsive, and still others
antisocial, researchers cannot presently conclude that any one personality trait or group of traits stands
out in substance-related disorders (Chassin et al., 2001
 Cognitive-Behavioral Views
• According to behaviorists, operant conditioning may play a key role in substance abuse
• They argue that the temporary reduction of tension or raising of spirits produced by a drug has a rewarding effect, thus
increasing the likelihood that the user will seek this reaction again
• Similarly, the rewarding effects of a substance may eventually lead users to try higher dosages or more powerful methods of
ingestion
• In addition, cognitive theorists argue that such rewards eventually produce an expectancy that substances will be
rewarding, and this expectation helps motivate individuals to increase drug use at times of tension.
• In support of these behavioral and cognitive views, studies have found that many people do in fact drink more alcohol or
seek heroin when they feel
• In one study, as participants worked on a difficult anagram task, a confederate planted by the researchers unfairly criticized
and belittled them
• The participants were then asked to participate in an “alcohol taste task,” supposedly to compare and rate alcoholic
beverages. The individuals who had been harassed drank more alcohol during the taste task than did the control participants
who had not been criticized.
• In a manner of speaking, the cognitive-behavioral theorists are arguing that many people take drugs to “medicate”
themselves when they feel tense.
• If so, one would expect higher rates of drug abuse among people who suffer from anxiety, depression, and other such
• And, in fact, more than 22 percent of all adults who suffer from psychological disorders
have been dependent on or abused alcohol or other substances within the past year
• A number of behaviorists have proposed that classical conditioning may also play a role
in substance abuse and dependence.
• Classical conditioning occurs when two stimuli that appear close together in time
become connected in a person’s mind, so that eventually, the person responds similarly
to each stimulus.
• Cues or objects present in the environment at the time drugs are taken may act as
classically conditioned stimuli and come to produce some of the same pleasure
brought on by the drugs themselves
• Just the sight of a hypodermic needle, drug buddy, or regular supplier, for example, has been
known to comfort people who abuse heroin or amphetamines and to relieve their withdrawal
symptoms.
• In a similar manner, cues or objects that are present during withdrawal distress may
produce withdrawal-like symptoms.
• One man who had formerly been dependent on heroin experienced nausea and other withdrawal
symptoms when he returned to the neighborhood where he had gone through withdrawal in the
past—a reaction that led him to start taking heroin again
Emotion Regulation
• It is generally assumed that one of the main psychological motives for
using drugs is to alter emotion—that is, drug use is reinforced because
it enhances positive feelings or diminishes negative ones.
• Unfortunately, people with substance use disorders may be less
successful than people without substance use disorders in regulating
negative emotion, at least when it comes to recruiting brain regions
and networks that support regulation, such as the prefrontal cortex.
• In addition, research has found that alcohol lessens negative emotions
such as stress and anxiety, but it also lessens positive emotions in
response to anxiety-provoking situations
• Other studies suggest that it is the sensory aspect of smoking (i.e.,
inhaling), not nicotine,
• that is associated with reducing negative emotion. In the study just
described, participants experienced a reduction in negative emotion
regardless of whether they were smoking cigarettes with or without
nicotine
Expectancies About Alcohol and Drug
Effects
• If substances don’t always reduce negative emotion, why do so many
people who drink or take drugs believe that it helps them unwind?
Expectation may play a role here—that is, people may drink not
because it actually reduces negative emotion but because they
expect it to do so.
• Similarly, people who believe (falsely) that alcohol will make them
seem more socially skilled are likely to drink more heavily than those
who accurately perceive that alcohol can interfere with social
interactions
 Sociocultural Views
• A number of sociocultural theorists propose that people are most likely to develop patterns of
substance abuse or dependence when they live under stressful socioeconomic conditions
• In fact, studies have found that regions with higher levels of unemployment have higher rates of
alcoholism.
• Other sociocultural theorists propose that substance abuse and dependence are more likely to
appear in families and social environments where substance use is valued, or at least
accepted.
• Researchers have, in fact, found that problem drinking is more common among teenagers whose
parents and peers drink, as well as among teenagers whose family environments are stressful
and unsupportive (
• Moreover, lower rates of alcohol abuse are found among Jews and Protestants, groups in which
drinking is typically acceptable only as long as it remains within clear limits, whereas
alcoholism rates are higher among the Irish and Eastern Europeans, who do not, on average,
draw as clear a line
• Also discuss the role of advertisement, celebrity culture etc
Treatment of Substance
Use Disorder
Inpatient Hospital Treatment
• Often, the first step in treatment for substance use disorders is called
detoxification, or detox for short.
• One detoxification approach is to have clients withdraw gradually
from the substance, taking smaller and smaller doses until they are off
the drug completely.
• A second—often medically p ­referred—detoxification strategy is to
give clients other drugs that reduce the symptoms of withdrawal
• Antianxiety drugs, for example, are sometimes used to reduce severe
alcohol withdrawal reactions such as delirium tremens and seizures
 Antagonist Drugs
• After successfully stopping a drug, people must avoid falling back into a pattern of
abuse or dependence.
• As an aid to resisting temptation, some people with substance-related disorders are
given antagonist drugs, which block or change the effects of the addictive drug
• Disulfiram (Antabuse), for example, is often given to people who are trying to stay
away from alcohol.
• By itself a low dose of this drug seems to have few negative effects, but a person who
drinks alcohol while taking disulfiram will experience intense nausea, vomiting,
blushing, faster heart rate, dizziness, and perhaps fainting.
• People taking ­disulfiram are less likely to drink alcohol because they know the terrible
reaction that awaits them should they have even one drink.
• Disulfiram has proved helpful, but again only with people who are motivated to take it
as prescribed
• In the realm of opioid dependence, several narcotic antagonists, such as
naloxone, are used to treat addicted people
• These antagonists attach to endorphin receptor sites throughout the brain
and make it impossible for the opioids to have their usual effect.
• Without the rush or high, continued drug use becomes pointless.
• Although narcotic antagonists have been helpful—particularly in emergencies,
to rescue people from an overdose of opioids—they can in fact be dangerous for
persons with opioid dependence. The antagonists must be given very carefully
because of their ability to throw such persons into severe withdrawal.
• So-called partial antagonists, narcotic antagonists that produce less severe
withdrawal symptoms, have also been developed
• Partial antagonists are now preferred over full antagonists by many clinicians to
help people withdraw from opioid use—an approach often called rapid
detoxification because the antagonists speed things along.
• The full antagonists remain the treatment of choice in emergency cases of
• Recent studies indicate that narcotic antagonists may also be useful in
the treatment of alcohol and cocaine dependence
• In some studies, for example, the narcotic antagonist naltrexone has
helped reduce cravings for alcohol
• Why should narcotic antagonists, which operate at the brain’s endorphin
receptors, help with alcoholism, which has been tied largely to activity at
GABA sites?
• The answer may lie in the reward center of the brain. If various drugs
eventually stimulate the same pleasure pathway, it seems reasonable that
antagonists for one drug may, in a roundabout way, affect the impact of
other drugs as well.
 Drug Maintenance Therapy
• A drug-related lifestyle may be a greater problem than the drug’s direct effects. Much of the damage
caused by heroin addiction, for example , comes from overdoses, unsterilized needles, and an
accompanying life of crime.
• Thus clinicians were very enthusiastic when methadone maintenance programs were developed in the
1960s to treat heroin addiction.
• In these programs, people with an addiction are given the laboratory opioid methadone as a substitute for
heroin. Although they then become dependent on methadone, their new addiction is maintained under safe
medical supervision.
• Unlike heroin, methadone can be taken by mouth, thus eliminating the dangers of needles, and needs to be
taken only once a day.
• At first, methadone programs seemed very effective, and many of them were set up throughout the United
States, Canada, and England. These programs became less popular during the 1980s, however, because of
the dangers of methadone itself
• Many clinicians came to believe that substituting one addiction for another is not an acceptable “solution”
for substance dependence, and many persons with an addiction complained that methadone addiction was
creating an additional drug problem that simply complicated their original one
Nicotine Replacement Treatments and
Medications (Only for Tobacco Use)
• Nicotine replacement therapy (NRT) substitutes a diff erent delivery system for nicotine (in
the form of gum, patches, inhalers, or e-cigarettes) to allay cravings while gradually reducing
dosages, with the goal of eliminating reliance on nicotine.
• Although NRT is often intended to alleviate withdrawal symptoms, the severity of
withdrawal is only minimally related to success in stopping smoking
• The nicotine in nicotine gum, available over the counter, is absorbed much more slowly and
steadily than that in tobacco.
• However, in hourly doses that deliver an amount of nicotine equivalent to one cigarette an
hour, the gum causes cardiovascular changes, such as increased blood pressure, that can be
dangerous to people with cardiovascular diseases.
• Although not everyone manages to completely wean themselves from using nicotine gum,
some experts believe that even prolonged, continued use of the gum is healthier than
obtaining nicotine by smoking because the carcinogens are avoided (de Wit & Zacny, 2000).
Psychodynamic Therapies
• Psychodynamic therapists first guide clients to uncover and work through the
underlying needs and conflicts that they believe have led to the disorder.
• The therapists then try to help the individuals change their substance-related styles
of living.
• Although often applied, this approach has not been found to be particularly
effective in cases of substance-related disorders
• It may be that drug abuse or dependence, regardless of its causes, eventually
becomes a stubborn independent problem that must be the direct target of
treatment if people are to become drug-free.
• Psychodynamic therapy tends to be of greater help when it is combined with other
approaches in a multidimensional treatment program (Lightdale et al., 2011,
2008).
 Behavioral Therapies
• A widely used behavioral treatment for substance-related disorders is aversion ­therapy, an approach
based on the principles of classical conditioning.
• Individuals are repeatedly presented with an unpleasant stimulus (for example, an electric shock) at
the very moment that they are taking a drug.
• After repeated pairings, they are expected to react negatively to the substance itself and to lose their
craving for it.
• Aversion therapy has been applied to alcohol abuse and dependence more than to other substance-
related disorders.
• In one version of this therapy, drinking behavior is paired with drug-induced nausea and
vomiting
• The pairing of nausea with alcohol is expected to produce negative responses to alcohol itself.
• Another version of aversion therapy requires people with alcoholism to imagine extremely
upsetting, repulsive, or frightening scenes while they are drinking.
• Here the pairing of the imagined scenes with alcohol is expected to produce negative responses to
alcohol itself.
• A behavioral approach that has been effective in the short-term treatment
of people who abuse cocaine and some other drugs is contingency
management, which makes incentives (such as cash, vouchers, prizes, or
privileges) contingent on the submission of drugfree urine specimens
• Behavioral interventions for substance abuse and dependence have usually
had only limited success when they are the sole form of treatment
• A major problem is that the approaches can be effective only when
individuals are motivated to continue with them despite their
unpleasantness or demands
• Generally, behavioral treatments work best in combination with either
biological or cognitive approaches (Higgins et al., 2011)
Psychotherapeutic Approaches
Cognitive-Behavioral Therapy
• Cognitive-behavioral treatments for substance-related disorders help clients identify and
change the behaviors and cognitions that keep contributing to their patterns of substance
use
• Practitioners of these approaches also help the clients develop more effective coping
skills—skills that can be applied during times of stress, temptation, and substance
craving.
• Perhaps the most prominent cognitive-behavioral approach to substance abuse and
dependence is relapse-prevention training
• The overall goal of this approach is for clients to gain control over their substance-related
behaviors.
• To achieve this, the individuals are taught to identify high-risk situations, appreciate the
range of decisions that confront them in such situations, change their dysfunctional
lifestyles, and learn from mistakes and lapses.
Relapse prevention training (continued)
• Several strategies typically are included in relapse-prevention training:
• (1) ­Therapists have clients keep track of their drinking behavior. Writing down the times, locations, emotions,
bodily changes, and other circumstances of their drinking, the individuals become more aware of the
situations that place them at risk for excessive drinking.
• (2) Therapists teach clients coping strategies to use when such situations arise. The individuals learn, for
example, to recognize when their drinking limits are being approached, to control their rate of drinking
(perhaps by spacing their drinks or by sipping them rather than gulping), and to practice relaxation
techniques, assertiveness skills, and other coping behaviors in situations in which they would otherwise be
drinking.
• (3) Therapists teach clients to plan ahead of time. The individuals may, for example, predetermine how many
drinks are appropriate, what to drink, and under what circumstances.
• This approach has been found to lower the frequency of intoxication and of binge drinking in some
individuals, although such gains often occur only after repeated relapse prevention treatments
• Individuals who are young and not physically dependent on alcohol seem to do best with this approach
• The treatment has also been used in cases of marijuana and cocaine abuse as well as with other kinds of
disorders such as sexual paraphilias
Couples Therapy
• Behaviorally oriented couples therapy has been found to achieve some
reduction in problem drinking as well as some improvement in
couples’ distress generally.
• This appears to be eff ective for straight, gay, and lesbian couples
• This treatment combines the skills covered in individual cognitive
behavior therapy, with a focus on the couple’s relationship and dealing
with alcohol-related stressors together as a couple.
• A meta-analysis of 12 studies found that behaviorally oriented couples
therapy was more eff ective than individual treatment approaches
(Powers, Vedel, & Emmelkamp, 2008).
Motivational Interviewing
• Motivational interviewing (MI) is an effective counselling method that
enhances motivation through the resolution of ambivalence. It grew
out of the Prochaska and DiClemente model.
• Miller and Rollnick's work in the field of addiction medicine, which
drew on the phrase 'ready, willing and able' to outline three critical
components of motivation.
• These were:
• the importance of change for the patient (willingness)
• the confidence to change (ability)
• whether change is an immediate priority (readiness).
Stages of Changes Strategies by
Practitioner
Alcoholic Anonymous/Narcotics Anonymus
• Many people who abuse drugs have organized among themselves to
help one another recover without professional assistance.
• The drug self-help movement dates back to 1935, when two Ohio men
suffering from alcoholism met and wound up discussing alternative
treatment possibilities.
• The first discussion led to others and to the eventual formation of a
self-help group whose members discussed alcohol-related problems,
traded ideas, and provided support. The organization became known
as Alcoholics Anonymous (AA).
• It offers peer support along with moral and spiritual guidelines to help people
overcome alcoholism.
• Different members apparently find different aspects of AA helpful. For some it
is the peer support; for others it is the spiritual dimension.
• Meetings take place regularly, and members are available to help each other 24
hours a day.
• By offering guidelines for living, the organization helps members abstain “one
day at a time,” urging them to accept as “fact” the idea that they are powerless
over alcohol and that they must stop drinking entirely and permanently if they
are to live normal lives.
• AA views alcoholism as a disease and takes the position that “Once an
alcoholic, always an alcoholic”
• It is worth noting that the abstinence goal of AA directly opposes the
controlled-drinking goal of relapse prevention training and several other
interventions for substance misuse
12 steps of AA/NA