SUBSTANCE ABUSE

The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and
physiological symptoms indicating that the individual continues using the substance despite
significant substance-related problems. Addictive behavior—behavior based on the pathological
need for a substance—may involve the abuse of substances such as nicotine, alcohol, Ecstasy, or
cocaine.

4 Distinctions are necessary:

(i) Substance abuse generally involves an excessive use of a substance resulting in

(1) potentially hazardous behavior such as driving while intoxicated or

(2) continued use despite a persistent social, psychological, occupational, or health problem.

(ii) Substance dependence includes more severe forms of substance-use disorders and usually
involves a marked physiological need for increasing amounts of a substance to achieve the
desired effects. Dependence in these disorders means that an individual will show a tolerance for
a drug and/or experience withdrawal symptoms when the drug is unavailable

(iii) Tolerance refers to the need for increased amounts of a substance to achieve the desired
effects—results from biochemical changes in the body that affect the rate of metabolism and
elimination of the substance from the body.

(iv)Withdrawal refers to physical symptoms such as sweating, tremors, and tension that
accompany abstinence from the drug.

ALCOHOL

Severity

Can range from mild, moderate to severe.

Mild - presence of two to three symptoms,

Moderate - four to five symptoms, and

Severe - six or more symptoms.

Epidemiology
Alcohol is one of the leading causes of death and disability globally and the same is true for
India.

A total of 3.2% of deaths worldwide are caused by alcohol every year. WHO claims that One
fourth to One third of male population drinks alcohol in India and neighbouring south Asian
countries and the use amongst women is increasing.

India

The 12‐month prevalence (AUD) in 2010 was 2.6% and that of alcohol dependence was 2.1%.

In 2012, 33.1% of all the road traffic accident deaths were attributable to drunk and driving.

The National Mental Health Survey of India 2015–16 found the prevalence of AUDs to be 9% in
adult men.

In India, the alcohol‐attributable fraction (AAF) of all cause deaths was found to be 5.4%.
Around 62.9%of all the deaths due to liver cirrhosis were attributable to alcohol use.

ETIOLOGY

Psychological and Sociocultural Theories

● Neighbourhood and the ease of availability of alcohol,

● Person’s income and the money available to buy alcohol, and their education and religious
beliefs.

● Religious beliefs and practices affect alcohol intake through moderating the effects of other
characteristics, with less likelihood that poverty, for example, predicts heavier drinking among
individuals with closer religious affiliations.

● Recent studies have found little evidence that introducing children to modest drinking in the
home impacts the risks for heavy drinking and alcohol problems.

Psychodynamic Theories

● People may drink heavily as part of dealing with self-punitive harsh superegos and to decrease
unconscious stress levels.

● Classic psychoanalytical theory claims that atleast some heavy drinkers may be fixated at the
oral stage of development and use alcohol to relieve their frustrations by taking the substance by
mouth.
● “addictive personality” is present in most individuals with AUDs and associated with lack of
control of intake of most substances and some foods.

Biological Contributors

● Close family members of individuals with an AUD have a fourfold increased risk.

● The identical twin of a person with an AUD is at higher AUD risk than is a fraternal twin.

● Adopted-away children of individuals with AUDs have a fourfold increased AUD risk, even if
not raised by parents with alcohol problems.

Alcohol Related Disorders as per DSM 5

● Alcohol Use Disorder - A problematic pattern of alcohol use leading to clinically significant
impairment or distress, as manifested by at least two of the following, occurring within a 12-
month period:

1. Alcohol is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover
from its effects.

4. Craving, or a strong desire or urge to use alcohol.

● Alcohol Intoxication - condition associated with drinking too much alcohol in a short
amount of time. It's also called alcohol poisoning. Alcohol intoxication is serious. It affects your
body temperature, breathing, heart rate, and gag reflex.

● Alcohol Withdrawal- If a person has been drinking heavily over a prolonged period, a rapid
decrease in blood alcohol levels can produce a withdrawal syndrome. Withdrawal includes a
coarse tremor of the hands, insomnia, anxiety, and increased blood pressure, heart rate, body
temperature, and respiratory rate.

TOBACCO USE

Cigarettes
Cigars,

Snuff,

Chewing tobacco,

Pipes.

(In decreasing order of use)

Tobacco Related Disorders

Among the most prevalent, deadly, and costly of substance dependencies. Tobacco does not
cause behavioral problems; therefore, few tobacco-dependent persons seek or are referred for
psychiatric treatment. Tobacco is a legal drug and most persons who stop tobacco use have done
so without treatment. A common, but erroneous, view is that, unlike alcohol and other illicit
drugs, most smokers do not need treatment.

Level of education attainment correlated with tobacco use. Of adults who had not completed
high school, 37 percent smoked cigarettes, whereas only 17 percent of college graduates smoked.

Psychiatric Patients

High proportion of psychiatric patients smoke. Approximately 50 percent of all psychiatric

outpatients, 70 percent of outpatients with bipolar I disorder, almost 90 percent of outpatients
with schizophrenia, and 70 percent of patients with substance use disorder smoke.

The causes of death due to tobacco consumption include:

● chronic bronchitis

● emphysema,

● bronchogenic cancer,

● fatal myocardial infarctions,

● cerebro vascular disease,

● cardiovascular disease,

● Chronic obstructive pulmonary disease and lung cancer.

Use of chewing tobacco and snuff (smokeless tobacco), cigar smoking : Oropharyngeal cancer
Tobacco smoke : lethal carcinogen, causes cancer of the lung, upper respiratory tract, esophagus,
bladder, and pancreas and probably of the stomach, liver, and kidney

Even second hand smoke (discussed below) causes a few thousand cancer deaths each year in the
United States.

DSM-5 includes a diagnosis for tobacco use disorder characterized by craving, persistent and
recurrent use, tolerance, and withdrawal if tobacco is stopped.

Dependence develops quickly as nicotine activates the ventral tegmental area dopaminergic
system (Reward system).

Tobacco Withdrawal

Withdrawal symptoms can develop within 2 hours of smoking the last cigarette; they generally
peak in the first 24 to 48 hours and can last for weeks or months. Common symptoms: intense
craving, tension, irritability, difficulty concentrating, drowsiness and paradoxical trouble
sleeping, decreased heart rate and blood pressure, increased appetite and weight gain, decreased
motor performance, and increased muscle tension. A mild syndrome of tobacco withdrawal can
appear when a smoker switches from regular to low-nicotine cigarettes.
PSYCHOSOMATIC DISORDERS

1. Somatic symptom disorder

Causes

The exact cause of somatic symptom disorder isn't clear, but any of these factors may play a role:

 Genetic and biological factors, such as an increased sensitivity to pain

 Family influence, which may be genetic or environmental, or both

 Personality trait of negativity, which can impact how you identify and perceive illness
and bodily symptoms

 Decreased awareness of or problems processing emotions, causing physical symptoms

to become the focus rather than the emotional issues

 Learned behavior — for example, the attention or other benefits gained from having an
illness; or "pain behaviors" in response to symptoms, such as excessive avoidance of
activity, which can increase your level of disability
Illness anxiety
 Is worrying excessively that you are or may become seriously ill. Patients believe that they
have a serious disease that has not yet been diagnosed, and they cannot be persuaded to the
contrary. The belief may be about a particular disease or with time they may transfer their belief
to another disease. Their convictions persist despite negative laboratory results, its benign
course, and reassurances from physicians. This interferes in their daily interaction with others
and they are often addicted to Internet searches about their feared illness.

Causes

The etiology is unknown. The social learning model may apply to this disorder with fear of
illness viewed as a request to play the sick role under insurmountable and insolvable problems. It
offers an escape that allows a patient to be excused from usual duties and obligations. The type
of the fear may also be symbolic of unconscious conflicts that are reflected in the type of illness
of which the person is afraid or the organ system selected (e.g., heart, kidney).

The exact cause of illness anxiety disorder isn't clear, but these factors may play a role:

 Beliefs. You may have a difficult time tolerating uncertainty over uncomfortable or unusual
body sensations. This could lead you to misinterpret that all body sensations are serious, so
you search for evidence to confirm that you have a serious disease.

 Family. You may be more likely to have health anxiety if you had parents who worried too
much about their own health or your health.

 Past experience. You may have had experience with serious illness in childhood, so
physical sensations may be frightening to you.

Factitious disorder

Factitious disorder is a serious mental disorder in which someone deceives others by
appearing sick, by purposely getting sick or by self-injury. Factitious disorder also can
happen when family members or caregivers falsely present others, such as children, as being ill,
injured or impaired.

Etiology

Early real illness coupled with parental abuse or rejection is typical. Patient recreates illness as
an adult to gain loving attention from doctors. Can also express masochistic gratification for
some patients who want to undergo surgical procedures. Others identify with an important past
figure who had psychological or physical illness. No genetic or biologic etiologic factors have
been identified.
Functional Neurologic Symptom Disorder (Conversion Disorder)

1. Biologic factors. The symptoms may be caused by an excessive cortical arousal that sets off
negative feedback loops between the cerebral cortex and the brainstem reticular formation.
Elevated levels of corticofugal output, in turn, inhibit the patient’s awareness of bodily sensation,
which may explain the observed sensory deficits in some patients with conversion disorder.
There is increased susceptibility in patients with frontal lobe trauma or other neurologic deficits.

2. Psychological factors. According to psychoanalytic theory, conversion disorder is caused by

repression of unconscious intrapsychic conflict and conversion of anxiety into a physical
symptom. Other factors are presence of personality disorder— avoidant, or histrionic and
impulse (e.g., sex or aggression) that is unacceptable to ego and is disguised through symptoms.

Clinical features

Paralysis, blindness, and mutism are the most common conversion disorder symptoms.
Conversion disorder may be most commonly associated with passive-aggressive, dependent,
antisocial, and histrionic personality disorders. Depressive and anxiety disorder symptoms often
accompany the symptoms of conversion disorder, and affected patients are at risk for suicide.

PAIN DISORDERS
Etiology

1. Behavioral. Pain behaviors are reinforced when rewarded (e.g., pain symptoms may become
intense when followed by attentive behavior from others or avoidance of disliked activity).

2. Interpersonal. Pain is a way to manipulate and gain advantage in a relationship (e.g., to

stabilize a fragile marriage).

3. Biologic. Some patients may have pain disorder, rather than another mental disorder, because
of sensory and limbic structural or chemical abnormalities that predispose them to pain.

4. Psychodynamics. Patients may be symbolically expressing an intrapsychic conflict through the

body. Persons may unconsciously regard emotional pain as weak and displace it to the body.
Pain can be a method to obtain love or can be used as a punishment. Defense mechanisms
involved in the disorder include displacement, substitution, and repression.

STRESS DISRODER
Posttraumatic Stress Disorder and Acute Stress Disorder Both posttraumatic stress disorder
(PTSD) and acute stress disorder are marked by increased stress and anxiety following exposure
to a traumatic or stressful event. Traumatic or stressful events may include being a witness to or
being involved in a violent accident or crime, military combat, or assault, being kidnapped, being
involved in a natural disaster or experiencing systematic physical or sexual abuse. The person
reacts to the experience with fear and helplessness, persistently relives the event, and tries to
avoid being reminded of it.

The stressors causing both acute stress disorder and PTSD are sufficiently overwhelming to
affect almost everyone. Persons reexperience the traumatic event in their dreams and their daily
thoughts (flashbacks); they are determined to avoid anything that brings the event to mind and
they undergo a numbing of responsiveness along with a state of hyperarousal. Other symptoms
are depression, anxiety, and cognitive difficulties such as poor concentration.

Etiology

1. Stressor By definition, a stressor is the prime causative factor in the development of PTSD
but not everyone experiences the disorder after a traumatic event. The stressor alone does not
suffice to cause the disorder. Clinicians must also consider individual’s pre-existing biologic and
psychosocial factors and events that happened before and after the trauma.

2. Risk factors Even when faced with overwhelming trauma, most persons do not experience
PTSD symptoms. About 60% of males and 50% of females have experienced some significant
trauma, whereas the reported lifetime prevalence of PTSD is only about 8%.

Biologic factors

Many neurotransmitter systems have been implicated and have led to theories about
norepinephrine, dopamine, endogenous opioids, and benzodiazepine receptors and the
hypothalamic– www.konkur.in pituitary–adrenal (HPA) axis. Studies suggest that the
noradrenergic and endogenous opiate systems, as well as the HPA axis, are hyperactive in at
least some patients with PTSD. There is also increased activity and responsiveness of the
autonomic nervous system, (elevated heart rates and blood pressure) and abnormal sleep
architecture (e.g., sleep fragmentation and increased sleep latency).

Natural disasters

Natural disaster can cause PTSD. Over the years, we have witnessed various kinds including
tsunamis in Indonesia, hurricanes in Florida, and earthquakes in Haiti. Data show rates as high as
50% to 75% and many survivors continue to live in fear and show signs of PTSD.

Psychotherapy
Psychodynamic psychotherapy may be useful in the treatment of many patients with PTSD. In
some cases, reconstruction of the traumatic events with associated abreaction and catharsis may
be therapeutic, but psychotherapy must be individualized because re-experiencing the trauma
overwhelms some patients. Psychotherapeutic interventions for PTSD include behavior therapy,
cognitive therapy, and hypnosis.

Crisis intervention

Crisis intervention and case management are short-term treatments aimed at helping persons with
adjustment disorders resolve their situations quickly by supportive techniques, suggestion,
reassurance, environmental modification, and even hospitalization, if necessary.

Adjustment disorders

Adjustment disorders are characterized by an emotional response to a stressful event and are
linked to the development of symptoms. Typically, the stressor involves financial issues, a
medical illness, or relationship problem. The symptom complex must begin within 3 months of
the stressor and includes anxious or depressive affect or may present with a disturbance of
conduct. The subtypes of adjustment disorder include adjustment disorder with depressed mood,
mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and
conduct, acute stress disorder, bereavement, and unspecified type.

Acute stress disorder (ASD) is an intense and unpleasant reaction that develops in the
weeks following a traumatic event. Symptoms typically last for one month or less. If symptoms
persist beyond one month, affected individuals are considered to have posttraumatic stress
disorder (PTSD).

Experiencing, witnessing, or being confronted with one or more traumatic events can cause
ASD. The events create intense fear, horror, or helplessness. An acute stress reaction
occurs when a person experiences certain symptoms after a particularly stressful event. The
word 'acute' means the symptoms develop quickly but do not last long. The events are usually
very severe and an acute stress reaction typically occurs after an unexpected life crisis.