SUBSTANCE

RELATED
DISORDER
Alit Aryani
Psychiatric Departement
Medicine Faculty Udayana University
INTRODUCTION
 Substance abuse problem cause significant disabilities
 Illicit substance abuse affects multiple area of functioning
and comorbid diagnosis occurs in about 60-70% of patients
with substance related disorder
 Substance abuse can mimic psychiatric disorder include
psychotic, anxiety, and depression
 NARCOTIC
TYPE I TYPE II TYPE III

For knowledge not For therapy and For therapy and

for therapy knowledge knowledge

High potention High potention Low potention

Heroin Morfin Codein

Coccain Pethidin
Canabis
 PSYCHOTROPIC
TYPE I TYPE II TYPE III TYPE IV TYPE V
For knowledge For Therapy For Therapy For Therapy For therapy
not for therapy

High Potention High Potention Hypnotic effect Low potention Antipsychotic,An

Hallucination Stimulant effect Anxiiolytic effect tidepresan, Anti
effect Manic,
Nootropic/Neurot
onic

mescaline, Amfetamin, Amobarbital Diazepam, Antipsychotic:Ha

psilocybin in methamfetamin Flunitrazepam Nitrazepam loperidol,
mushroom, LSD Fensyklydin Buprenorfin
(Lysergic Acid Glutetimid Fenobarbital Risperidon
Derivation) Sekobarbital Pentazosin Alprazolam AntidepresanAm
MDMA Metylfenidat
ytriptilin,
(4methylen Sertralin
dioxyamphetami
ne) Anti mania:
Lithium
Neurotonic :
Piracetam
 ADDICTIVE SUBSTANCE
ALCOHOL CAFFEINE NICOTINE INHALANT
Type A : 1-5% Coffee, Energic solvents such
: Bir, Green drink as toluene,
Sands gasoline and
Type B : 5- gases such as
20%: Anggur nitrous oxide
Martini
Type C : 20-
55%
: Wiski Brandi
Tequila
Coccaine
Kafeine

MDMA Amphetamine
Nikotine
 Opioid (Heroin)

Morphine

Cannabis
Alkohol
TERMINOLOGI
 Dependence : repeated use of a drug or chemical
substance, with or without physical dependence
 Abuse : use of any drug by self administration, that
deviates from approved social and medical pattern
 Misuse : similar to abuse but usually applies to
drugs prescribed by physicians that are not used
properly
 Addiction : The repeated (compulsive) and increase
use of substance.
 Intoxication (>> Dose) : a reversible syndrome
caused by a spesific substance that affects one or more
of the following mental functions : memory,
orientation, mood, judgement, behavior, social,
occupational
 Withdrawal : A substance spesific syndrome that
occur after stopping or reducing the amount of the
drug or substance that has been used regularly over a
prolonged period of time
PATOFISIOLOGI ADIKSI
Psychodinamic

1. organo-biologik
genetic factor
Neurotransmitter defisit

2. Psychologic factor
oral phase fixation
personality

3. Sosio cultural/environment
Stress, unhappy family
black market
weakness of law regulation
ETIOLOGIC

INDIVIDUAL ENVIRONMENT

SUBSTANCE
INDIVIDUAL FACTOR
 EXPERIMENTAL USE
 LOW SELF ESTEEM
 LOW SELF CONFIDENCE
 ANTISOCIAL PERSONALITY
 LOOKING FOR SELF IDENTITY
 HAVING STRESOR/ PROBLEM
 IMMATURE DEFENCE MECHANISM
 RELIGY
 BROKEN HOME
 GRADE OF DRUG USER
I. EXPERIMENTAL USE
II. SOCIAL USE/ HAVING FUN/
RECREATIONAL USE
III. SITUATIONAL USE
IV. ABUSE
V. DEPENDENCE /TOLERANCE
-WITHDRAWL
EVALUATION
 Often difficult to detect and evaluate
 They are often manipulative, denial, and fear the
consequences of acknowledging the problem  It is
necessary to obtain information from other sources
 Substance abuse is frequently associated with
personality disorders (antisocial, borderline,
narcissistic)
1.Anamnesis : History ; continuous or episodic
2.Toxicology (urine, hair, blood test, saliva)
3. Physical examination
 Subcutaneus or intravenous abusers : AIDS, scars, abcess,
infection, thrombophlebitis
 Snorter of coccaine, heroin, other drugs : deviated of nasal
septum, nasal bleeding, rhinitis
 Smokers of marijuana or other drugs, inhalant abusers :
bronchitis, asthma, chronic respiratory condition
4. Psychometry : ASSIST, ASI
DSM V
 Alcohol Related Disoder
 Caffeine Related Disoder
 Cannabis Related Disoder
 Hallusinogen Related Disoder
 Inhalant Related Disoder
 Opioid Related Disoder
 Sedative Hypnotic or Anxiolytic Related Disoder
 Stimulant Related Disoder
 Tobacco Related Disoder
 Other (or Unknown) Related Disoder
 Non Substance Related Disoder
ALKOHOL
 ALCOHOL
production of somnolence and decreased neuronal activity but not
powerful in attenuating pain

Potentially lethal in overdose, produce cross tolerance with other

depressants, physically addicting with withdrawal symptoms.

Neurochemical Effects of Ethanol

Changes in dopamine, tying in the effects of alcohol on pleasure
centers in ventra tegmental area of brain, actions on GABA-A
receptor enhance acure sedating, sleep, anticonvulsant, muscle
relaxing
 TOLERANCE
3 process: behavioral, pharmacokinetic, pharmacodynamic

Craving
Activation of limbic system, the orbitofrontal and insular cortex,
as well as in the cerebellum

Blackout
Memory impairment for the period when a person was drinking
heavily but remained awake
 SLEEP IMPAIRMENT
Suppresses REM, inhibits stage 4 sleep, sleep fragmentation,
intense and disturbing dreams

Cerebellar degeneration
Unsteadiness of gait, mild nystagmus, problems with standing
steadiness

Other effects on the Central Nervous System

Wernicke’s and Korsakoff’s Syndrome

Peripheral neuropathy
Numbness of extremities, tingling and paresthesias
 GASTROINTESTINAL PROBLEMS
Acute inflamation of esophagus/stomach, esophageal vein
bleeding, fatty liver, hepatitis, cirrohis, pancreatitis

Cerebrovascular and cardiovascular problems

Increase blood pressure, elevate LDL and TG, enhance risk MI
and thrombosis, alcoholic cardiomyopathy

Blood producing system

Decrease production of leucocyte, erythrocytes, impair platelets

Cancer
Tumors of head neck esophagus stomach, liver, colon, lungs,
breast
 FETAL ACOHOL EFFECTS
Fetal death, spontaneous abortion, mental retardation, small head,
low birth weight, facial abnormalities, atrial septal defect,
syndactyly

Other problems
Testicular atrophy, bone fractures, cataracts, dental difficulties,
muscle wasting, increase risk of accident
 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
occuring 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 unsuccesful efforts to cut down or control
alcohol use
 3. Agreat deal of time is spent in activities to use alcohol
 5. Recurrent alcohol use
 6. Continued Alcohol use despite having interpersonal problem
 7. Important activities are reduced because of alcohol use
 8. Tolerance
 9. Withdrawal
 ALCOHOL INTOXICATION
 A. Recent ingestion of alcohol
 B. Clinically significant problematic behavioral or psychological changes (eq.
inapropriate sexual or aggressive behavior, mood lability, impaired judgement)
that developed during or shortly after alcohol ingestion
 C. One (or more) of the following signs or symptoms developing during, or
shortly after alcohol use :
 1. Slurred speech
 2. Incoordination
 3. Unsteady gait
 4. Nystagmus
 5. Impairment in attention or memory
 6. Stupor or coma
 D. The signs or symptoms are not attributable to another medical condition and are
not better explained by another mental disorder, including intoxication with
another substance.
 SYMPTOMS
INTOXICATION WITHDRAWAL
Alcohol Maladaptive behavior and Autonomic hyperactivity
psychological change Insomnia
Slurred speech Increased hand tremor
Incoordination Nausea and vomiting
Unsteady gait Transient hallucination
Nystagmus Psychomotor agitation
Impairment memory or Anxiety
attention Grandmal seizure
Stupor or Coma Delirium Tremen’s (DTs)
 1. INTERVENTION
Principles of motivational interviewing to break through denial
and help patient recognize the adverse conseqences for drinking
alocohol.

2. Detoxification and Rehabilitation

First step is a thorough physical examination to find out serious
medical disorders

Second step is to offer rest, adequate nutrition, oral multiple

vitamis, especially Thiamine
 MEDICATIONS
1. Acamprosate – analog of amino acid neurotransmitter taurine,
structurally resembles GABA. 2000 mg/day

2. Naltrexone – long acting, oral, opioid antagonist.

15-20% better outcomes than placebo. 50-150 mg/day or
injection 380 mg.

3. Disulfiram-the alcohol-sensitizing agent. Many side effects:

mood swings, psychosis, possibility an increase of peripheral
neuropathy, rare fatal hepatitis.

4. Topiramate-anticonvulsant
5. Ondansentron-serotonin 3 receptor antagonist
6. SSSRI, GABA-B receptor agonist Baclofen
7. antipsychotic
OPIOID
 OPIOID

 DSM V
 Opioid Use Disorder
 Opioid Intoxication
 Opiod Withdrawal
 Other Opioid Induced Disorders
 Unspecified Opiod Related Disorder.
SYMPTOMS
WITHDRAWAL INTOXICATION
Opioid Reduction of opioid use Drowsiness coma
Pain Slurred speech
Nausea, Vomiting Impairment attention or
diarrhea memory
Insomnia Pupillary constriction
Anxiety Blood pressure ↓
Pupillary dilation Respiration rate↓
Fever Heart rate ↓
Respiration rate ↑ Behavioral psychological
Heart rate ↑ change
Dysphoric mood
Restlessness Therapy : naloxone
injectie
Therapy : Substitusi
methadon, buprenorfin
WITHDRAWL
DIFFERENTIAL DIAGNOSIS

Opioid-induced
Opioid Induced Opioid Induced
Psycotic
Mood Disorder Sleep Disorder
Disorder
TREATMENT
Self-
help
groups.
Methadone
Individualized drug
maintenance
counseling. treatment

Supportive- Opioid
expressive antagonist
psychotherapy . treatment

Opioid
Outpatient
agonist-
drug-free
treatment. antagonist
treatment.
STIMULANT-
AMPHETAMINE
 AMPHETAMINE (OR AMPHETAMINE-LIKE)
 In addition to amphetamine itself, some members of this
class include:
- methamphetamine (METH)
- methcathinone, phentermine,
- methylenedioxyamphetamine (MDA)
- 3,4-methylenedioxymethamphetamine (MDMA)
- methylenedioxyethylamphetamine (MDEA)
 Have classic psychostimulant properties

• Amphetamine-like, example:
- methylphenidate
- caffein
 DIAGNOSTIC CRITERIA
STIMULANT USE DISORDER
 The individual must have a history of at least 2 of the following within
12 month period:
 Often taken in larger period
 Tolerance
 Withdrawal
 Craving
 Greater use of drug than intended
 Persistent desire, Inability to cut back on use
 A great deal of time using drug
 A reduction in social, occupational, or recreational activities
 Continued use despite being aware that use is associated with
problem
 PHARMACOLOGY
 The drugs produced acute psychomotor stimulant effect
 The pharmacokinetics of METH are dependent on route of
administration and dose.
 Regardless of the route of administration, the reinforcing effects of
METH:
 Euphoria
 Power and confidence
 Decreased need for sleep
 Increased energy and concentration.
 SYMPTOMS

WITHDRAWAL INTOXICATION
Amphetamin Cessation amphetamine Recent use of amphetamine
e (stimulant) use Problematic behavioral and
2 or more symptom : psychological changes
fatigue 2 or more symptom :
Depresion Tachycardia/Bradycardia
Hipersomnia Pupilary dilation
Appetite ↑ Elevated or lowered blood
Nightmare, vivid pressure
Inability in concentration Perspiration/chills
Psychomotor agitation or Nausea, vomiting
retardation Weight loss
Depressed breath
Chest pain
Psychomotor agitation or
retardation
COCCAIN. STIMULAN

WITHDRAWAL INTOXICATION
1. fatique
1. Tachycardia / bradycardia
2. Nigthmare
2. pupillary dilation
3. Insomnia
3. Blood pressure ↗ / ↙
4. Retardation psychomotor
4. Nausea and vomiting
Therapy
5. Agitation
Antidepresant
6. Chest pain, aritmia
 Bupropion
 MAOI 7. Confusion , seizure
 SSRI Therapy :
 Fluoxetin  Lithium
 Sertralin  Dilantin
 CAFFEIN
Effect Psychostimulans, diuretic
↗ blood pressure
Intoxication Withdrawal

1. Anxiety 1. Fatique
2. Restlessness 2. Anxiety
3. Insomnia 3. Nausea and vomiting
4. diuresis 4. Headache
5. Muscle – twitching 5. Dysphoric mood
6. Tachycardia 6. Difficulty concentrating
7. Agitation
8. Rambling flow of thought
and speech
TREATMENT
 Psychological and behavioral treatment approaches
are the primary modality
 Pharmacotherapy:
 Bupropion, in combination with behavioral
group therapy
 Antidepresan (withdrawal)
 Mood stabilizer (manic)
SEDATIVE HYPNOTIC
BENZODIAZEPIN
BENZODIAZEPIN
INTOXICATION
 Benzodiazepine intoxication can be associated with
behavioral disinhibition, potentially resulting in hostile or
aggressive behavioral.
 Benzodiazepine intoxication is associated with less respiratory
depression than barbiturate intoxication.
Withdrawal
Anxiety, apprehension, dysphoria, pessimism, irritability,
obsessive rumination, and paranoid ideation.
 Disturbances of sleep
Insomnia, altered sleep-wake cycle, daytime drowsiness
 SYMPTOMS

Intoxication Withdrawal
Benzodiazepine Recent use of sedative Reduction in sedative
(sedative Maladaptive behavioral Anxiety,
and Psychological
hypnotic) change Autonomic Hyperactivity
Slurred speech Hand tremor
Incoordination Insomnia
Steady gait Nausea or vomiting
Nystagmus Nightmare
Impairment cognition Grandmal seizure
Stupor or coma Hallucination visual, tactil
 CANNABIS

 Pharmacology of cannabinoid
THC is the is the primary psychoactive constituent in
cannabis
Two kinds of receptor of cannabinoid, CB1 and CB2
- CB1 : CB1 receptors is found primarily in the brain
and mediates the psychological and behavioral effects
of THC
- CB2 : CB2 receptor is associated with the immune
system and appears to modulate inflammatory response
INTOXICATION
 Most people use cannabis in order to experienced a “high”,
characterized by euphoria, relaxation and perceptual alteration
including time distortion, and the intensification of ordinary
experiences such as eating, watching films, listening to music, and
engaging in sex.
 Cognitive changes include impaired short-term memory and
attention that make it easy for the user to become lost in pleasant
reverie and difficulties to sustain goal-oriented mental activity.
 Motor skills, reaction time, other psychomotor activity are impaired
CANNABIS AND
SCHIZOPHRENIA
 There are some evidence stating that the use of cannabis
can precipitate schizophrenia in vulnerable individuals
 Psychotic disorders involve disturbances in dopamine
neurotransmitter. THC is known to increase dopamine
secretion
 A research in British found that individuals with history of
heavy chronic cannabis use who developed psychosis were
ten times more likely to have family histories of
schizophrenia.
 ANXIETY INDUCTION
 Some users report increased anxiety level, panic, the fear of
being angry, and depression after using cannabis
 There is an increased in heart rate by 20-50% only in
minutes after the use
 Postural hypotension may occur
Withdrawal
Withdrawal symptoms could be manifested as anxiety,
insomnia, irritable, apettite disturbance, and depression
 SYMPTOMS

INTOXICATION WITHDRAWAL
Canabis : Recent use of cannabis Cessation of cannabis use
Problematic behavioral and 3 or more symptom
Marijuana psychological change Anxiety,
Hasish 2 or more symptom Insomnia
Ganja Conjunctival injection Irritability
Increased appetite Depressed mood
Dry mouth Decrease appetite
tachycardia Restlessness
euphoria Physical symptom :
perceptual alteration abdominal pain, tremor, fever,
intensification of ordinary headache
experiences such as eating,
watching films, listening to
music, and engaging in sex.
 NICOTINE
Withdrawal :
1.Dysphoric/depressed mood
2.Insomnia
3.Angry, irritability
4.Anxiety
5.Concentration difficulties
6.Agitation
7.Palpitation
8.Increase Appetite
Therapy
•Nicotine – replacement therapies
- Nicotine gum (nicorette)
- Nicotine patches (nicoderm)
- Nicotine nasal spray (nicotrol)
•Non nicotine  bupropion (zyban)
Clonidine
•Psychoterapi
•
 HALUSINOGEN
Intoxication
1. halusination, ilusi, depersonalisation, derealisation
2. Two or more symptoms :
 Pupillary dilation
 Tachycardia
 sweating
 Palpitation
 Blurred vision
 Tremor
 Incoordination
Therapy
• Benzodiazepin  clonazepam
• Anti convulsant : valproic acid, carbamazepine
LSD
Magic mushroom
Preventive Program

Individual
Level

Peer level

Family Level

Social &
Community Level

School Level
COMORBIDITIES
SCHIZOPHRENIA

MANIC
DEPRESSION
BIPOLAR DISORDER
MENTAL RETARDATION
CONDUCT DISORDER
PERSONALITY
DISORDER
 F10 SAMPAI F 19
GANGGUAN MENTAL DAN
PERILAKU AKIBAT PENGGUNAAN
ZAT PSIKOAKTIF
 F 10 : GMP akibat penggunaan alkohol
 F 11 : GMP akibat penggunaan opioida
 F 12 : GMP akibat penggunaan kanabinoida
 F 13 : GMP akibat penggunaan sedative hipnotika
 F 14 : GMP akibat penggunaan kokain
 F 15 : GMP akibat penggunaan stimulansia
 F 16 : GMP akibat penggunaan halusinogenika
 F 17 : GMP akibat penggunaan tembakau/nikotin
 F 18 : GMP akibat penggunaan pelarut yg mudah menguap
 F 19 : GMP akibat penggunaan zat multiple
SUB DIAGNOSIS
 F 1x.0 Intoksikasi Akut
 F 1x.1 Penggunaan yang merugikan
 F 1x.2 Sindrom Ketergantungan
 F 1x.3 Keadaan Putus Zat
 F 1x.4 Keadaan Putus Zat dengan Delirium
 F 1x.5 Gangguan Psikotik
 F 1x.6 Sindrom Anemsik
 F 1x.7 Gangguan Psikotik Residual Onset lambat
 THERAPHY
 Medication : according to symptoms and accompanying
comorbidities (Antidepresan, Antipsychotic, Anti Anxiety,
Mood Stabilizer).
 Non Psychopharmaca :
 Suportif Psychotherapy
 Brief Psychoteraphy
 Addiction Counseling.
 Psychotherahy : Cognitive Behavior Theraphy, Motivational
Interviewing, Psychodinamic Psychotheraphy