MODULE 14: SUBSTANCE-RELATED AND

ADDICTIVE DISORDERS

Module Overview

Module 14 covers the different substance-related and addictive disorders including

their clinical presentation, epidemiology, comorbidity, and etiology. The discussion
includes substance intoxication, substance use disorder, and substance withdrawal.

Module Outline

 14.1. Clinical Presentation

 14.2. Comorbidity
 14.3. Etiology

Module Learning Outcomes

 Describe the clinical presentations of substance-related and addictive disorders.

 Describe the epidemiology, comorbidity, and etiology of substance-related and
addictive disorders.

14.1. Clinical Presentation

Section Learning Objectives

 Define substances and substance abuse.

 Describe properties of substance abuse.

Substance Abuse

Substance-related disorders are among the most prevalent psychological disorders.

While this disorder was previously classified as “drug abuse,” the evolvement of the
disorder has sparked abuse of other substances such as alcohol, tobacco, and caffeine,
thus better classifying the disorder as abuse of substances.

Substances are any ingested materials that cause temporary cognitive, behavioral,
and/or physiological symptoms within the individual. These changes that are observed
directly after or within a few hours of ingestion of the substance are classified
as substance intoxication. Substance intoxication symptoms vary greatly, and are
dependent on the type of substance ingested.

Repeated use of these substances, or frequent substance intoxication can develop into
a long-term problem known as substance abuse. Abuse occurs when an individual
consumes the substance for an extended period of time, or has to ingest large amounts
of the substance to get the same effect a substance provided previously. The need to
continually increase the amount of ingested substance is also known as tolerance. As
tolerance builds, additional physical and psychological symptoms present, often
causing significant disturbances in an individual’s personal and/or professional life.
Individuals with substance abuse are often spending a significant amount of time
engaging in activities that revolve around their substance use, thus spending less time
in recreational activities that once consumed their time. Sometimes, there is a desire
to reduce or abstain from substance use, however, cravings
and withdrawal symptoms often prohibit this from occurring on one’s own attempts.
Common withdrawal symptoms include but are not limited to: cramps, anxiety
attacks, sweating, nausea, tremors, and hallucinations. Depending on the substance
and the tolerance level, most withdrawal symptoms last anywhere from a few days to
a week. For those with extensive substance abuse- or multiple substances being
abused- withdrawal should be closely monitored in a hospital setting to avoid serious
possible consequences such as seizures, stroke, or even death.

Substance Intoxication. The individual must have recently ingested a substance.

Immediately following the ingestion of this substance, significant behavioral and/or
psychological change is observed. In addition, physical and physiological symptoms
present as a direct result of the substance ingested.

Substance Use Disorder. The individual must experience significant impairment

or distress over the course of 12-months due to their use of a substance. Distress or
impairment can be described as any of the following: inability to complete or lack of
participation in work, school or home obligations/activities; increased time spent on
activities obtaining, using, or recovering from substance use; impairment in social or
interpersonal relationships; use of substance in a potentially hazardous situation;
psychological problems due to recurrent substance abuse; craving for substance; an
increase in the amount of substance used over time (i.e. tolerance); difficulty reducing
the amount of substance used despite desire to reduce/stop using the substance;
and/or withdrawal symptoms. While the number of these symptoms may vary among
individuals, only two symptoms are required to be present for a diagnosis of the said
disorder.

Substance Withdrawal. It is the diagnosis when there is cessation or reduction of

a substance that has been used for a long period of time. Individuals undergoing
substance withdrawal will experience physiological and/or psychological symptoms
within a few hours after cessation/reduction. These symptoms cause significant
distress or impairment in daily functioning.

Types of Substances Abused

The substances that are most often abused can be divided into three categories based
on how they impact one’s physiological state: depressants, stimulants, and
hallucinogens/cannabis/combination.

Depressants. Depressant substances such as alcohol, sedative-hypnotic drugs, and

opioids, are known to have a depressing, or inhibiting effect on one’s central nervous
system; therefore, they are often used to alleviate tension and stress. Unfortunately,
when used in large amounts, they can also impair an individual’s judgment and motor
activity.

Stimulants. The two most common types of stimulants abused are cocaine and
amphetamines. Unlike depressants that reduce the activity of the central nervous
system, stimulants have the opposite effect, increasing the activity in the central
nervous system. Physiological changes that occur with stimulants are increased blood
pressure, heart rate, pressured thinking/speaking, and rapid, often jerky behaviors.
Because of these symptoms, stimulants are often used for their feelings of euphoria, to
reduce appetite, and prevent sleep.

Hallucinogens/Cannabis/Combination. Both hallucinogens and cannabis

produce sensory changes after ingestion. While hallucinogens are known for their
ability to produce more severe delusions and hallucinations, cannabis also has the
capability of producing delusions or hallucinations, however, this typically occurs only
when large amounts of cannabis are ingested. The most common synthetic forms of
hallucinogens are PCP, Ketamine, LSD and Ecstasy. More commonly, cannabis has
been known to have stimulant and depressive effects, thus classifying itself in a group
of its own due to the many different effects of the substance. Cannabis is derived from
a natural plant- the hemp plant and its most commonly known type is marijuana.

14.2. Comorbidity

Section Learning Objectives

 Describe the comorbidity of substance-related and addictive disorders.

Substance abuse in general has a high comorbidity rate within itself (meaning abuse
of multiple different substances), as well as with other mental health disorders.
Researchers believe that substance abuse disorders are often secondary to another
mental health disorder, as the substance abuse develops as a means to “self-medicate”
the underlying psychological disorder. Alcohol and drug dependence are twice as more
likely in individuals with anxiety, affective, and psychotic disorders than the general
public. There is a strong relationship between substance abuse and mood, anxiety,
posttraumatic stress, and personality disorders.

14.3. Etiology

Section Learning Objectives

 Describe the biological, cognitive, behavioral, and sociocultural causes of

substance-related and addictive disorders.
Biological

Similar to other mental health disorders, substance abuse is genetically influenced. It

is different than other mental health disorders in that if the individual is not exposed
to the substance, they will not develop substance abuse. Heritability of alcohol is
among the most well studied substances, likely due to the fact that it is the only legal
substance. Twin studies indicate that the genetic component of drug abuse is stronger
than drug use in general, meaning that genetic factors are more significant for abuse
of a substance over nonproblematic use.

Unique to substance abuse is the fact that both genetic and familial influence are both
at play. Biologically, the individual may be genetically predisposed to a substance
abuse; additionally, the individual may also be at risk due to their familial environment
where their parents and/or siblings are also engaging in substance abuse.

The brain reward system is a longstanding belief that explains how drug abuse begins
and is maintained. Majority of research on the brain reward system has focused on the
mesocorticolimbic dopamine system, as it appears that this area is the primary reward
system of most substances that are abused.

Cognitive

Cognitive theorists have focused on the beliefs regarding the anticipated effects of
substance use. Defined as the expectancy effect, drug-seeking behavior is presumably
motivated by the desire to attain a particular outcome by ingesting a substance. The
expectancy effect can be defined in both positive and negative forms. Positive
expectations are thought to increase drug-seeking behavior, while negative
experiences would decrease substance use. Those with alcohol abuse reported
expectations of tension reduction, enhanced sexual experiences, and improved social
pleasure. Additionally, observing positive experiences, both in person and through
television or social media also shapes our drug use expectancies.

Behavioral

Operant conditioning has been implicated in the role of developing substance use
disorders. Substance abuse is positively and negatively reinforced due to the effects
of a substance. Positive reinforcement occurs when the substance use is increased due
to the positive or pleasurable experiences of the substance. Negative reinforcement,
or the increase of a given behavior due to the removal of a negative effect, also plays a
role in substance abuse in two different ways. First, many people ingest a substance as
an escape from their unpleasant life- whether it be physical pain, stress, or anxiety, to
name a few. The second is during symptoms of withdrawal. To eliminate these
withdrawal symptoms, the individual will consume more of the substance, thus again
escaping the negative symptoms and enjoying the “highs” of the substance.
Sociocultural

Peer attitudes, perception of one’s friend’s drug use, pressure from peers to use
substances, and beliefs about substance use are among the strongest predictors of drug
use patterns. This is particularly concerning during adolescence when patterns of
substance use typically begin.

There is a strong relationship between second generation substance abusers. The

increased likelihood of family members’ substance abuse is likely related to both a
genetic predisposition, as well as the accepting attitude of the familial environment.

Another sociocultural view on substance abuse is stressful life events, particularly

those related to financial stability. Prevalence rates of substance abuse is higher in
poorer people. Furthermore, additional stressors such as childhood abuse/trauma,
negative work environments, as well as discrimination are also believed to contribute
to the development of a substance use disorder.