1. Substance –Related disorders
Med 2017

2. Objectives
-To understand substance related disorders ,their etiologic factors and grasp the related conditions . -Understand symptoms of intoxication and withdrawal of alcohol and other commonly abused substances -Understand intervention and treatment startegies

3. F1x.0 Acute Intoxication Df.:
A transient condition following the administration of psychoactive substance resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses
Closely related to dose levels
Uncomplicated
With trauma or other medical complications
With delirium
With coma
With convulsions
Pathological intoxication (applies only to alcohol)

4. Mental and Behavioural Disorders Due to Psychoactive Substance Use
Disorders due to use of: F10.x alcohol F11.x opioids F12.x cannabinoids F13.x sedatives or hypnotics F14.x cocaine F15.x other stimulants (caffeine) F16.x hallucinogens F17.x tobacco F18.x volatile solvents F19.x multiple drugs and other psychoactive drugs

5. 10 Broad Principles of Drug Use and Problems
Drug use is a chosen behavior Drug problems emerge gradually and occur along a continuum of severity Once well-established, drug problems tend to become self-perpetuating Motivation is central to prevention and intervention Drug use responds to reinforcement Drug problems do not occur in isolation, but as part of behavior clusters There are identifiable and modifiable risk and protective factors for problem drug use Drug problems occur within a family context Drug problems are affected by a larger social context Relationship matters

7. What is Addiction? Addiction is A Brain Disease
Charaterized by:
Compulsive Behavior
Continued abuse of drugs despite negative consequences
Persistent changes in the brain’s structure and function

8. What Environment Factors Contribute to Addiction?
Stress
Early physical or sexual abuse
Witnessing violeance
Peers who use drugs
Drug availability

9. Drugs and Brain Reinforcement Systems

10. Pleasure pathway
Mesolimbic dopaminergic tract from the ventral tegmental area to the nucleus accumbens
VTA releases dopamine not only into the nucleus accumbens, but also into the septum, the amygdala, and the prefrontal cortex. The nucleus accumbens then activates the individual’s motor functions, while the prefrontal cortex focuses his or her attention.
Mesocortical/limbic median forebrain bundle MFB forms pleasure reward bundle whose activation leads to the repetition of the gratifying action to strengthen the associated pathways of the brain (Olds and Milner)
All drugs of abuse have either receptors directly on (eg mu opiods) or indirectly through interneurons (GABA).
The VTA then releases dopamine not only into the nucleus accumbens, but also into the septum, the amygdala, and the prefrontal cortex. The nucleus accumbens then activates the individual’s motor functions, while the prefrontal cortex focuses his or her attention.
These regions are connected by what is called the pleasure or reward bundle. In neuroanatomical terms, this bundle is part of the medial forebrain bundle (MFB), whose activation leads to the repetition of the gratifying action to strengthen the associated pathways in the brain. First described by James Olds and Peter Milner in the early 1960s, the MFB is a bundle of axons that originates in the reticular formation, crosses the ventral tegmental area, passes through the lateral hypothalamus, and continues into the nucleus accumbens as well as the amygdala, the septum, and the prefrontal cortex.

11. Drugs and Brain Reinforcement Systems

13. Withdrawal State
Symptoms occurring on absolute or relative withdrawal of a substance after repeated and prolonged use of the substance
Uncomplicated
With convulsions

14. Dependence Syndrome (Addiction)
A strong desire or sense of compulsion to take the substance („craving“)
Difficulties in controlling substance-taking
Withdrawal sy characteristic for the substance
Evidence of tolerance
Progressive neglect of pleasures and interests
Persisting with substance use despite clear evidence of overtly harmful consequences
Physical dependence
Psychic (psychological) dependence

15. Reasons to suspect an underlying psychiatric disorder…
Sx precede use of substance
Sx persist after discontinuation (eg. One month)
Sx out of proportion or unusual for offending substance
Cross sectional, longitudinal, epidemiology, FHx and past tx responsiveness suggest a specific axis 1 pathology

16. Who is susceptible and why?
Alcoholism
Who is susceptible and why?

17. Bio/Psycho/Social Model
1) Individual who responds to alcohol in a certain way. Positive reward.
2) Personality characteristics that encourage use. Impulsiveness.
3) Member of social group where
A) pressure to drink. College Fraternity.
B) confusion over drinking ground rules.
Drink with meals or drink to get drunk?

18. Physiological factors
Biological susceptibility
Genetic evidence
Family history
Children of alcoholics (COA)
If father alcoholic,
25% sons affected
5-10% of daughters

19. Genetic evidence Twin studies MZ 100% genes DZ 50% genes
Reared together
Alcoholism in
55% MZ twins
28% DZ twins

20. Adoption studies Father alcoholic: 18% sons affected.
Father non-alcoholic:
5% sons affected.
Daughters less affected.

21. Males particularly susceptible
Male limited. TYPE II alcoholism.
More severe, early onset.
Many negative consequences.
Trouble with law, at school, on job.
Environment plays less of a role but can lessen the severity.
Adopted COA’s did better than those raised with alcoholic parent.

22. Milieu limited. TYPE 1 All women and 75% of men.
Less severe, later onset.
May not be treated.
Personality factors important.
Reward seekers. Psych dependence.
Environment plays key role.
Family and social groups.
Intoxication as recreation.
Good time depends on drinking.

23. What is inherited? High initial tolerance.
Different rate of metabolism.
Alcohol -> acetaldehyde ->
acetate -> CO2 and H20
COA’s higher levels of acetaldehyde.
Metabolize alcohol quicker.
Hence higher tolerance

24. Acetaldehyde effects
Acetaldehyde may combine with brain chemicals to give opiate-like high
Acetaldehyde also toxic to liver and heart.
Medical complications

25. Brain response to novelty
Brain waves to novel stimuli.
P3 waves.
Less reaction in alcoholics.
And in COA’s before start drinking.
Need more stimulation?

26. Psychological characteristics
Related to biology?
Reward seeking.
Impulsive.
Easily bored.
Risk takers
Gregarious
Push the limits
Act out

27. Social factors Alcoholism high in some cultures, Low in others.
High risk situations.
Coping skills

28. Alcoholism is higher in cultures where
No ground rules.
Mixed messages from different individuals and groups.
Getting drunk okay? Funny?
Heavy drinking is encouraged.
Drinking a sign of masculinity or adulthood.

29. How Alcohol Attacks the Brain A guide to the sequential damage alcohol inflicts on neural tissue
First, alcohol
3. Finally, alcohol batters the brainstem as it affects heart rate, body temperature, appetite and consciousness, a dangerous and potentially fatal condition.
affects the
forebrain and
assaults motor
coordination and
decision making
2. Then, Alcohol
knocks out
the midbrain,
and you lose
control over
emotions and
increase chances of a
blackout.

30. Mild to moderate psychological symptoms:
Feeling of jumpiness or nervousness
Feeling of shakiness
Anxiety
Irritability or easily excited
Emotional volatility, rapid emotional changes
Depression
Fatigue
Difficulty with thinking clearly

31. Mild to moderate physical symptoms:
Headache – general, pulsating
Sweating, especially the palms of the hands or the face
Nausea and vomiting
Loss of appetite
Insomnia, sleeping difficulty
Paleness
Rapid heart rate (palpitation)
Eyes, pupils different size ( enlarged, dilated pupils)
Skin, clammy
Abnormal movements
Tremor of the hands
Involuntary, abnormal movements of the eyelids

32. Severe Symptoms:
A state of confusion and hallucinations (visual) – known as delirium tremens
Agitation
Fever
Convulsions (which may result in death)
“Black outs”- when the person forgets what happened during the drinking episode

33. ETOH Intoxication (GAS-IN) Withdrawal (PINT ASA)
Gait abnormality, attentional, stupor/coma (risk of asp pneum), slurred speech, incoordination, nystagmus. Also mood lability, dec judgement, inappropriate physical/sexual fxn
Withdrawal (PINT ASA)
Perceptual abn, insomnia, nausea, tremor, onset (hrs-days), facial flushing, agitation, seizures, anxiety (ANS hyperactivity: inc HR, HTN)
Shakes 6-12h, hallucinations 8-12, sz 12-24, DT’s >72h
Inc risk w malnutrition, physical illness, depression, fatigue
Short term Complications
Withdrawal, sz’s, blackouts, DT’s, psychotic sx, depression, suicide, coma / pneumonia
Long term Complications:
Medical: cirrhosis, CHAOS, malnutrition, ETOH persisting amnestic disorder (Wernicke’s-ataxia, confusion, nystagmus: Rx thiamine, Korsakoff’s: 20% irreversible anterograde amnesia due to thiamine deficiency in the mammilary bodies) / ETOHlic dementia.
Tests
of hepatic enzymes (and possibly of γ-glutamyltransferase
and carbohydrate-deficient transferrin)

34. Alcohol dependence syndrome
Narrowing of the drinking repertoire.
Strong drink seeking behavior.
High tolerance.
Withdrawal symptoms.
Awareness of a compulsion to drink.
Drinking to avoid withdrawal.
Reinstatement of dependence after abstinence.

35. Physiological Effects of Chronic Alcohol Abuse
Excessive, chronic alcohol use increases the risk of
liver disease
cardiovascular disease
cancer
pancreatitis
Type II diabetes
neurological disorders
most severely, Korsakoff’s syndrome

36. Amnesic Syndrome
Impairment of recent memory (learning of new material)
Absence of defect in immediate recall, of impairment of consciousness, and of generalized cognitive impairment
History of chronic use of psychoactive substance (Korsakov’s psychosis or syndrome)

37. Are you an alcoholic?
1. Do you lose time from work due to drinking? 2. Is drinking making your home life unhappy? 3. Do you drink because you are shy with other people? 4. Is your drinking affecting your reputation? 5. Have you ever felt remorse after drinking? 6. Have you ever got into financial difficulties as a result of drinking? 7. Do you turn to lower companions and an inferior environment when drinking? 8. Does your drinking make you careless of your family’s welfare? 9. Has your ambition decreased since drinking? 10. Do you crave a drink at a definite time? 11. Do you want a drink the next morning? 12. Does drinking cause you to have difficulty in sleeping? 13. Has your efficiency decreased since drinking? 14. Is drinking jeopardizing your job or business? 15. Do you drink to escape from worries or trouble?
16. Do you drink alone? 17. Have you ever had a complete loss of memory as a result of drinking? 18. Has your physician ever treated you for drinking? 19. Do you drink to build up your self-confidence? 20. Have you ever been to a hospital or institution because of drinking?

38. Approaches to Treatment for Alcoholism
Approaches include behaviorally and psychologically based treatments (e.g., cognitive behavioral therapy, contingency management) and spiritually based treatments (e.g., Alcoholics Anonymous). It is curious to note that although AA embraces the disease concept of alcoholism, it embraces a spiritual rather than a scientific or medical approach to its treatment.

39. Table 9.2

42. F16.x Mental Disorders Due to Use of Hallucinogens
Lysergid acid diethylamide (LSD), psilocybin, mescaline, phencyclidine
Acute intoxication: distorted perception (optic hallucinations and illusions); unpredictable and dangerous behaviour
Withdrawal syndrome has not been described

43. Cannabinoids

45. Mechanism of Action

46. Effects

47. Withdrawal

48. Tobacco

50. F14.x,15.x Mental Disorders Due to Use of Stimulants
Cocaine, amphetamine, metamphetamine (pervitine), phenmetrazine, methyphenidate, MDMA (ecstasy, methylenedioxymetamphetamine)
Positive mood, activity, planning, diminished need of sleep
Tachycardia, arrhythmia, hypertension, hyperthermia, intracerebral haemorrhage
Withdrawal symptoms: severe craving, depression, decreased energy, fatigue, sleep disturbance
Prolonged use can trigger paranoid psychoses, impulsivity, aggressivity, irritability, suspiciousness and anxiety states

51. Amphetamines Psychopharmacology Adverse effects
D and L enantiomers have different effects. Direct and indirect sympathomimetics (mostly cause vesicular release of DA or NA).
Adverse effects
CVA, cardiac (MI, HTN), GI ischemic colitis, HIV/hepatitis
Designer amphetamines (which also have 5HT properties) inc use
Rx indications
ADHD, narcolepsy, depression +/- augmentation

52. Amphetamines
Amphetamines and amphetamine-related drugs are central nervous system stimulants.
The past decade has seen a marked increase in the popularity of amphetamines use.
Types:
Amphetamines – group subtances including predominantly amphetamine and methamphetamine.
Ecstacy- group substances- including MDMA (3,4-Methylenedioxymethamphetamine) and its analogues.

53. Amphetamines Effects of abuse Short term
Loss of appetite, rapid breathing and heartbeat, high blood pressure, and dilated pupils
Fever, sweating, headache, blurred vision, and dizziness (high dose)
Flushing, pallor, very rapid or irregular heartbeat, tremors, loss of coordination, and collapse (very high dose)
death

54. 2. Long term effects
Short-term effects are exaggerated
Various illness related to vitamin deficiencies and malnutrition
More prone to illness
Amphetamine psychosis – a mental disturbance similar to paranoid schizophrenia
Kidney damage, lung problems, strokes, or other tissue injury may result

55. Amphetamines Chronic Use Psychotic syndrome
Tolerance can develop. Abusers sometimes forego food and sleep in a form of binging known as a “run,” injecting as much as 1 gm q 2-3 hrs over several days until the user runs out of the drug or is too disorganized to continue.
Chronic abuse can lead to psychotic behavior, characterized by intense paranoia, visual and auditory hallucinations, and out-of-control rages that can be coupled with extremely violent behavior.
As much as 50 percent of the dopamine-producing cells in the brain can be damaged after prolonged exposure to relatively low levels of methamphetamine. Serotonin-containing nerve cells may be damaged even more extensively. Whether this toxicity is related to the psychosis is unknown
Psychotic syndrome
Similar (paranoia, perceptual abn) to SCZ except increased VHs, appropriate affect, hyperactivity, hypersexuality, confusion/incoherent but usually no thought disorder
Rx: haldol

56. Withdrawal symptoms
Due to tolerance to some effects
Become psychologically or physically dependent
Fatigue, long but troubled sleep, irritability, intense hunger, and moderate to serve depression, which may lead to suicidal behaviour
Fits of violence may also occur
These disturbances can be temporarily reversed if the drug is taken again

57. F11.x Mental Disorders Due to Use of Opioids
Morphine, heroin (diacetylmorphine), codeine, pethidine, methadone
Heroin:
dependence develops within two weeks of daily use
overdose may lead to death
withdrawal symptoms are extremely unpleasant
needle-sharing represents a serious risk of transmission of HIV and hepatitis B + C viruses
treatment of the withdrawal state – buprenorphine, benzodiazepines, spasmolytics; in serious cases of dependence heroin is replaced by methadone

58. F12.x Mental Disorders Due to Use of Cannabinoids
Marijuana (marihuana) is a colloquial term for dried leaves and flowers of cannabis plant (Cannabis sativa L.)
Δ9-tetrahydrocannabinol (Δ9-THC) is responsible for the psychoactive properties of the cannabis plant
Complex physiological functions of the cannabinoid system: motor coordination, memory procession, control of appetite, pain modulation and neuroprotection
Summary of adverse effects:
acute: anxiety, panic, impaired attention, memory, reaction time and psychomotor performance and coordination, increased risk of road accident, and increased risk of psychotic symptoms among vulnerable persons
chronic: chronic bronchitidis, a cannabis dependence syndrome, subtle impairments of attention, short-term memory and ability to organize and integrate complex information

59. F13.x Mental Disorders Due to Use of Sedatives and Hypnotics
benzodiazepines – potentiate the action of GABA
risk of dependence
short-acting benzodiazepines: alprazolam, flunitrazepam, oxazepam, lorazepam, temazepam
long-lasting benzodiazepines: diazepam, clorazepate, chlordiazepoxide, etc.
withdrawal state can be accomplished with epileptic seizures
interaction with alcohol may induce qualitative changes of consciousness

60. F14.x,15.x Mental Disorders Due to Use of Stimulants
Cocaine, amphetamine, metamphetamine (pervitine), phenmetrazine, methyphenidate, MDMA (ecstasy, methylenedioxymetamphetamine)
Positive mood, activity, planning, diminished need of sleep
Tachycardia, arrhythmia, hypertension, hyperthermia, intracerebral haemorrhage
Withdrawal symptoms: severe craving, depression, decreased energy, fatigue, sleep disturbance
Prolonged use can trigger paranoid psychoses, impulsivity, aggressivity, irritability, suspiciousness and anxiety states

61. F16.x Mental Disorders Due to Use of Hallucinogens
Lysergid acid diethylamide (LSD), psilocybin, mescaline, phencyclidine
Acute intoxication: distorted perception (optic hallucinations and illusions); unpredictable and dangerous behaviour
Withdrawal syndrome has not been described

62. F16.x Mental Disorders Due to Use of Hallucinogens
Lysergid acid diethylamide (LSD), psilocybin, mescaline, phencyclidine
Acute intoxication: distorted perception (optic hallucinations and illusions); unpredictable and dangerous behaviour
Withdrawal syndrome has not been described

63. F18.x Mental Disorders Due to Use of Volatile Solvents
Toluene, acetone, adhesives, petrol, cleaning fluids, etc.
Acute intoxication: euphoria, disorientation, incoordination, slurred speech; optic hallucinations
The way of use is very dangerous

65. Mental Disorders Due to Use of Volatile Solvents
Toluene, acetone, adhesives, petrol, cleaning fluids, etc.
Acute intoxication: euphoria, disorientation, incoordination, slurred speech; optic hallucinations
The way of use is very dangerous

68. 2 approaches Treatment settings Psychotherapy Abstinence
Harm reduction
Treatment settings
Outpatient
Residential tx programs
Psychotherapy

69. WHO 2006

70. Treatment Motivational Interviewing Cognitive Behavioural Therapy
Social Skills Training
Contingency Management
Pharmacological therapy - A number of medications have been approved for the treatment of substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short acting, or the newer long acting form (under the brand name Vivitrol).
Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion (Zyban or Wellbutrin), Modafinil (Provigil) and more.
It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious
Community Reinforcement Approach
Exposure therapy
Behavioral Marital Therapy

71. Change theory STAGES OF CHANGE Precontemplation Contemplation
Prochaska & DiClemente
STAGES OF CHANGE
Precontemplation
Contemplation
Preparation
Action
Maintenance
RECOMMENDING ABSTINENCE if:
Pregnant or trying to get pregnant, taking meds that interact with alcohol, contraindicated by medical conditions, alcohol dependent, want to find out if dependent

72. Psychotherapy Motivational Interviewing
Focuses on the present interests, concerns and perspectives of the individual
Focuses on the resolution of ambivalence
Elicits and selectively reinforces change talk
Is a method of communicating rather than a set of techniques
It is fundamentally a way of being with and for people- “facilitative approach to communication that evokes natural change”.
Illicits the persons intrinsic motivation for change.

73. Motivational interviewing
Four General Principles
Express Empathy
Acceptance facilitates change
Develop Discrepancy
Between behaviour and personal goals
Roll with resistance
Patient primary resource for solutions
Signal to respond differently
Support self-efficacy
Patient responsible for choosing and carrying out change

74. CBT for substance
Cognitive Behavior Therapy for substance has two main components: functional analysis and skills training.
Functional Analysis: Working together, the therapist and the patient try to identify the thoughts, feelings and circumstances of the patient before and after they drank or used drugs. This helps the patient determine the risks that are likely to lead to a relapse.
Functional analysis can also give the person insight into why they drink or use drugs in the first place and identify situations in which the person has coping difficulties.
Skills Training: If someone is at the point where they need professional treatment for their alcohol or drug dependence, chances are they are using alcohol or drugs as their main means of coping with their problems. The goal of cognitive behavior therapy is to get the person to learn or relearn better coping skills.

75. WHO 2006

76. WHO 2006