Substance-Related Disorders

I. General

A. Background
1. Diagnosis
Pre-DSM-III substance abuse was classified as a personality disorder part of ones character; antisocial tendency

2. DSM-IV organization for substancerelated disorders

General criteria for substance abuse and substance dependence Substance-specific criteria for intoxication and withdrawal

B. Substance Abuse
DSM-IV criteria for abuse (p. 381) A. Substance use leading to significant impairment or distress as manifested by one or more of the following in a 12-month period: 1) failure to fulfill major role obligations 2) recurrent use when hazardous 3) recurrent substance-related legal problems 4) recurrent social or interpersonal problems B. Never met for dependence for the substance

C. Substance Dependence
Case of Tim DSM-IV criteria for dependence (p. 382)

DSM-IV criteria for dependence

Substance use leading to significant impairment or distress as manifested by 3 or more of the following in a 12-month period:
1. Tolerance (need more or diminished effect) 2. Withdrawal (characteristic syndrome or use to avoid symptoms) 3. Often use more or for longer than intended 4. Desire or unsuccessful efforts to cut down 5. Great deal of time getting, using, or recovering 6. Important activities given up or reduced 7. Use despite recurrent physical or psychological problem - Specify with/without physiological dependence

D. Intoxication and Withdrawal

Substance-specific criteria for intoxication and withdrawal Withdrawal syndrome tends to be opposite of intoxication syndrome for a given substance Opponent-process theory = opposite effects in withdrawal create crash when coming down from a high
Leads to cycle of taking drug to avoid withdrawal (a dependence symptom)

Substance-Related Disorders
II. Alcohol Use Disorders

A. Background
Early research Jellineks alcoholic stages
Stage 1 = prealcoholic social drinker who begins drinking to reduce stress Stage 2 = prodromal becomes obsessed with alcohol; drinks in secret; blackouts Stage 3 = crucial cant stop once they start; denial; nutritional problems; social problems; life falls apart Stage 4 = chronic like the wino on the street; sobriety followed by binges, benders

A. Background (cont.)
Jellineks two alcoholic types
1. Gamma alcoholic = person who loses control of use
Typical in U.S.

2. Delta alcoholic = person cannot abstain, but can control use

Typical in Europe

B. Course and Statistics

Prevalence is 13% in U.S. differs by culture
Similar rates among whites and AfricanAmericans Higher rates among Latino males Higher rates among Native Americans Lower rates among many Asian populations

B. Course and statistics (cont.)

Sex difference in rates
As much as 5:1 males:females (depends on age group)

Alcohol use is most common between ages 18 and 24 Disorder onset peaks in the 20s and mid30s
Women tend to onset later than men

B. Course and statistics (cont.)

Course tends to be chronic with waxing and waning
Stress exacerbates; tends to wane later in life

Effects of alcohol differ throughout course

Tolerance usually develops (alcohol has less effect) If tolerance is low, high blood alcohol levels can be lethal

C. Related Problems
High comorbidity
Among most frequent of comorbid conditions Comorbidity cuts across classes of disorders (depression, anxiety, ASPD, psychotic, bulimia) Contribution to crime

C. Related Problems (cont.)

Effects on a fetus
Fetal alcohol syndrome (FAS)
Constellation of physical, cognitive and behavioral problems in children exposed to alcohol in the womb Not clear how much alcohol is needed to produce the syndrome; most cases are in women with chronic alcohol use disorder

C. Related Problems (cont.)

Effects later in life
Wernicke-Korsakoff Syndrome
two-stage disease resulting from severe and chronic alcohol use or severe nutritional deficits in thiamine (vitamin B12)
First stage = sudden onset of global confusion, affected muscle movements, and problems with eyes (double vision or paralysis) Second stage = sudden development of profound amnesia for recent memory with intact remote and immediate memory cannot learn new things

Mean onset is in the 40s

D. Causal Influences
1. Biological factors

Alcoholism runs in families Twins data: MZ > DZ (genetic influence) Strains of inbred mice differ in level of preference for alcohol Strains of inbred mice differ in level of sensitivity to alcohol Children of alcoholics show low sensitivity to alcohol, which predicts later alcoholism

D. Causal influences (cont.)

2. Neurobiological factors

GABA system alcohol may serve its anxiolytic (anti-anxiety) function Serotonin system alcohol appears to dampen effects Dopamine system alcohol has its rewarding/pleasurable effects
One version of the D2 receptor gene more common among alcoholics than controls

D. Causal influences (cont.)

3. Psychological and environmental factors
Need access to alcohol (env.) What psychological factors are related to alcohol use?

Positive reinforcement (social acceptance, social competence) Self-medication Expectancies (beliefs about alcohols effect) Personality (impulsivity, negative emotionality)

E. Treatments
1. Aversion treatments
Disulfiram (Antabuse) causes build up of acetaldehyde (byproduct in metabolism of alcohol) high levels cause sickness (nausea, vomiting) Problem: only works when taken; doesnt cure dependence, just prevents use

E. Treatments (cont.)
2. Inpatient hospital

Usually 30-day stay

Common 12-step program how to stay sober (not a cure) Based on medical model alcoholism is a powerful disease that requires a higher power to control Little well-controlled research on its effectiveness

3. Alcoholics Anonymous (AA)

E. Treatments (cont.)
4. Motivational interviewing (MI)

Effective method of engaging people in treatment Contrast to traditional blame approach

Cognitive behavioral type treatment confront beliefs; change behavior (avoid cues for use)

5. Relapse prevention

Summary
General criteria for abuse and dependence (same across substances) Substance-specific criteria for intoxication and withdrawal Multidimensional influences on alcohol use disorders Treatment of alcohol use disorders ranges from aversion therapy to relapse prevention