1. Substance–Related Disorders Dr Nesif J. Ai-Hemyary MBChB–FICMS(Psych.)

2. Introduction  Substance-abuse problems cause significant disabilities for a relatively high percentage of the population in most of world areas.  Illicit substance abuse affects multiple areas of functioning and co morbid diagnosis occurs about 60-75% of patients with substance- related disorders.  In USA more than 15% of persons over the age of 18 are diagnosed with these disorders.  In Iraq,there are no accurate figures about the prevalence of these disorders,but anecdotal reports refer to the presence of these disorders and to the increasing number of people affected by them.  Substance induced syndromes can mimic the full range of psychiatric illnesses, including: mood, psychotic and anxiety disorders.  In clinical practice substance use disorders must always be considered in the differential diagnosis.

3. Classification of substances  Brain altering compounds are referred to as substances in DSM-IV-TR and the related disorders as substance-related disorders.  These disorders are characterized by changes in mood,behavior, and cognition as a result of continued and prolonged use of the offending drug or toxin.  There are many classes of substances that are associated with these disorders.

4. 1- Alcohol. 2- Amphetamine and amphetamine-like substances like MDMA. 3-Cocaine. 4-Caffeine. 5-Hallucinogens: mescaline, pilocybin, LSD, these are cold psychodelics. 6-Inhalants: solvents like toluene, gasoline, glue and gases like nitrous oxide. 7-Nicotine. 8-0pioids. 9-Phencyclidine(PCP). 10-Sedatives, hypnotics and anxiolytics. 11-Prescribed drugs and over the counter medication (OTC): these include pain killers. 12-Anabolic-androgenic steroids: testosterone and human growth hormone (HGT).

5. Important concepts and terms  Dependence: -the repeated use of a drug or chemical substance, with or without physical dependence. Physical dependence: indicates an altered physiologic state due to repeated administration of a drug, the cessation of which results in a specific syndrome called (withdrawal syndrome).

6. Criteria for substance dependence  A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12- month period: 1.Tolerance, as defined by either of the following: a-a need for markedly increased amounts of the substance to achieve intoxication or desired effect. b-markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal, as manifested by either of the following: a-the characteristic withdrawal syndrome for the substance. b-the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms. 3.The substance is often taken in larger amounts or over a longer period than was intended. 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

7. 5-A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances),use the( e.g., chain smoking), or recover from its effects. 6-Important social,occupational, or recreational activities are given up or reduced because of substance use. 7-the substance use is continued despite knowledge of having persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance ( e.g., current cocaine use despite recognition of cocaine- induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

8. Abuse  Use of any drug, usually by self administration in a manner that deviates from approved social or medical patterns.  Criteria for substance abuse: A- A maladaptive pattern of substance use leading to clinically significant impairment or distress,as manifested by one (or more ) of the following, occurring within a 12-month period: 1-recurrent substance use resulting in a failure to fulfill major role obligations at work,school or home (e.g., repeated absences or poor work performance related to substance use; substance related absences, suspensions, or expulsions from school; neglect of children or household).

9. 2- Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use). 3- Recurrent substance related legal problems( e.g., arrest for substance related disorder conduct). 4- Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance9 e.g., arguments with spouse about consequences of intoxication, physical fights). B- The symptoms have never met the criteria for substance dependence for this class of substance.

10.  Addiction: The repeated and increased use of a substance, the deprivation of which gives rise to symptoms of distress and an irresistible urge to use the agent again and which leads also to physical and mental deterioration. The term is no longer included in the official nomenclature,having been replaced by the term dependence.

11.  Intoxication: A reversible syndrome caused by a specific substance( e.g., alcohol) that affects one or more of the following mental functions: memory, orientation, mood,judgment,and behavioral,social,or occupational functioning.  Withdrawal: A substance specific syndrome that occurs after stopping or reducing the amount of the drug or the substance that has been used regularly over a prolonged period of time. the syndrome is characterized by physiologic signs and symptoms in addition to psychological changes such as disturbance in thinking, feeling and behavior ( also called abstinence syndrome or discontinuation syndrome.)

12.  Tolerance : A phenomenon in which,after repeated administration,a given dose of a drug produces a decreased effect or increasingly larger doses must be administered to obtain the effect observed with the original dose.

13. Etiology  A- Psychodynamic factors: 1 - According to the classical theories substance abuse is a masturbatory equivalent,a defense against homosexual impulses or a manifestation of oral regression. Recent psychodynamic formulation relate substance use to depression or regard it as a reflection of disturbed ego function. 2-childhood problems. 3-personality disorders. 4-role of family and society. 5-behavioral theories: regard it as a learned behavior.  B- Genetic factors: A strong evidence from studies of twins,siblings, adoptees brought up separately indicates that the cause of alcohol abuse has a genetic component. Many less conclusive data show that other types of substance abuse/dependence have a genetic pattern in their development.

14.  C- Neuro-chemical factors: For most substances of abuse,with the exception of alcohol,researchers have identified particular neurotransmitters through which, or neurotransmitter receptors on which, the substances have their effects. The opiates for example on opiate receptors. The major neurotransmitters possibly involved in developing substance abuse/dependence are:opioids,catecholamines (particularly dopamine), and Gamma Aminobutyric Acid (GABA).  Systems of particular importance are the dopaminergic neurons in the ventral tegmental area which project to the cortical and limbic regions especially the nucleus accumbens. This pathway may be involved in the sensation and reward and may be the major mediator of the effects of such substances like amphetamine and cocaine. the locus coerulus,the largest group of adrenergic neurons, probably mediate the effects of the opiates.

15. Complications of substance abuse/dependence 1-Medical complications: a- Intoxication. b- Withdrawal. c- Chronic toxic effects( liver cirrhosis, cancer, etc…). d-Harmful effects due to the method of use: iv administration and shared needles lead to transmission of dangerous diseases like HIV/AIDS,hepatitis, etc…,in smoking inhalation may cause bronchogenic cancer. e- Indirect effects: neglect of hygiene,exercise and poor nutrition.

16. 2- Psychological complications: a- Personality disorders. b- Psychiatric disorders:mood disorders, anxiety disorders, psychotic disorders, etc… c-suicide. d-organic mental disorders like dementia, amnesic disorder,etc… e-co morbidity: about 65% of substance abuse patients have another mental disorder. 3- Socio-economic complications: a-family discord. b-child abuse. c- financial losses. d-accidents. e- crimes.