Lifespan Psychopathology Substance Abuse and Dependence Duane E. Dede, Ph.D. Clinical and Health Psychology

Substance Abuse & Dependence

Substance Abuse A residual category (i.e., a diagnosis of last resort) for patients whose substance use produces problems but does not fulfill the more rigorous criteria for Substance Dependence. Not applicable for caffeine and nicotine

Substance Abuse-DSM Failure to fulfill important roles Repeated use when it is physically dangerous Use despite recurrent legal problems Use despite interpersonal problems

Substance Dependence The user has taken a substance frequently enough to produce clinically important distress or impaired functioning, as well as certain behavioral characteristics. Use is maladaptive and patterned. Found in connection with all classes of drugs but caffeine. Substance dependence does not have to be intentional; can develop from medicinal use.

Substance Intoxication An acute clinical condition resulting from recent overuse of a substance. Anyone can become intoxicated; this is the only substance-related diagnosis that can apply to a person who uses a substance only once. All substances but nicotine have a specific syndrome of intoxication.

Substance Withdrawal A collection of symptoms (specific for the class of substance) that develop when a person who has frequently used a substance discontinues or markedly reduces the amount used. All substances except caffeine, cannabis, PCP, the hallucinogens, and the inhalants have an officially recognized withdrawal syndrome.

Tolerance Requiring more and more of a specific substance to accomplish the desired effect or to avoid aversive physiological reactive symptoms. Markedly diminishing effect with continued use of the same amount of the substance

Craving* Somoza (1995) rated preference Craving Scale Cocaine/Alcohol (1.81) Opiates/Cocaine (1.32) Cocaine/Marijuana (18.4) Craving Scale Marijuana (1.0) Alcohol (10.0) Cocaine (18.4) Opiates (24.3)

Craving vs. Withdrawal Craving appears to be distinct from “psychological symptoms” (Mezinskis, 1995) Cue extinction procedures and behavioral procedures should be used for craving. Pharmacological agents can directly attenuate craving (Ex. Naltrexone-ReVia)

C A G E Cut down Annoyed Guilty Eye-opener

Sedative, Hypnotic, or Anxiolytic Intoxication Slurring of speech Poor coordination Unsteady walking Nystagmus Impaired attention or memory Poor judgment Mood lability Stupor or coma

Sedative, Hypnotic, or Anxiolytic Withdrawal Autonomic overactivity (sweating, rapid heartbeat) Worsened tremor of hands Sleeplessness Nausea or vomiting Short-lived hallucinations or illusions (visual, tactile, or auditory) Speeded-up psychomotor activity Inappropriate aggressive or sexual behavior Anxiety Grand mal seizures

Criteria for Phencyclidine Intoxication Recent use, leading to maladaptive behavior including assault, belligerence, impulsivity, agitation, unpredictability, and impaired judgment. Two of the following symptoms develop within an hour of use of the substance Nystagmus Rapid heartbeat or high blood pressure Numbness or decreased response to pain Trouble walking Trouble speaking Rigid muscles Abnormally acute hearing Coma or seizures

Opioid Intoxication Shortly after using an opioid, one may feel depression, anxiety, feeling speeded up or slowed down psychomotor activity as well as impaired role function During or shortly after the use, the patient develops constricted pupils and one of the following: Sleepiness or coma Slurred speech Impaired memory or attention

Opioid Withdrawal Recent reduced use and have been given an opioid antagonist Within minutes or days of using the antagonist, 3 or more of the following symptoms develop: Dysphoria Nausea or vomiting Aching muscles Tearing or runny nose Dilated pupils, piloerection, or sweating Diarrhea yawning Fever Sleepiness

Cannabis Intoxication After use of cannabis, the patient develops clinically significant behavioral and psychological changes that are maladaptive. Includes motor performance deficits, anxiety, euphoria, impaired judgment, social withdrawal and the sensation that time has slowed down Within 2 hours, two or more symptoms occur: Red eyes Increased appetite Dry mouth Rapid heart Rate

Other Cannabis related disorders Cannabis-Induced Psychotic D/O, with Delusions: Usually persecutory delusion, lasting for a few days. Rare in U.S. and more likely to be seen in juveniles Most U.S. patients who have delusions associated with cannabis probably have other diagnoses as well Cannabis-Induced Anxiety D/.O:

Cocaine Intoxication Blunted affect, hypervigilance, interpersonal sensitivity, anger, anxiety, changes in sociability, impaired judgment and role functioning Two or more of the following: Slowed or rapid HR Dilated pupils Raised or lowered BP Chills or sweating Nausea or vomiting Weight loss Speeded up or slowed down psychomotor activity Muscle weakness, shallow or slowed breathing, chest pain, or heart arrhythmias Coma, confusion, dyskinesias, dystonia or seizures

Cocaine Withdrawal Within a few hours to days of reduced intake, the pt. develops dysphoric mood and 2 or more of the following: Fatigue Unpleasant, vivid dreams Excessive sleepiness or sleeplessness Increase in appetite Speeded up or slowed down psychomotor activity

Other Substance-related D/O’s Anabolic steroids- driven by powerful urge for attractiveness and athletic ability. Effects- improved physique, euphoria, increased libido, and occasional aggression. Withdrawal symptoms include depression, fatigue, restlessness, insomnia, loss of appetite and libido. Nitrous Oxide- An anesthetic inhalant that produces lightheadedness and mild euphoria. Therefore, AKA-laughing gas People in many cultures chew betal nuts to achieve a mild high or sensation of floating. Kava- South Pacific pepper plant. Causes sedation and loss of coordination and weight.

Substance Disorders-Summary Very common primary or comorbid disorders in clinical settings Important to get accurate past and current histories about patterns of use Know the manifestations of the various intoxication and withdrawal phases Accurate descriptions of the behavior is important Discuss with your supervisor the best course of action if you feel your patient in intoxicated

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