This document discusses substance related disorders including definitions of terms like intoxication, withdrawal, tolerance, dependence, and abuse. It covers the phenomenology, clinical picture of intoxication, withdrawal, tolerance, physical and psychological dependence. It discusses major substances of abuse like alcohol, cannabis, opioids. It covers epidemiology, etiology including genetics. Impacts of substance use in college are discussed regarding academic performance, physical/psychological health, finances, and legal issues. Treatment options and approaches are outlined including managing intoxication/withdrawal, behavioral interventions, pharmacotherapy, treating co-occurring disorders and medical conditions.

1. SUBSTANCE RELATED DISORDERS
DR. SUSHMA RATHEE
A S S I S T A N T C L I N I C A L P S Y C H O L O G I S T , P G I M E R ,
C H A N D I G A R H
E M A I L : S U S H M A R A T H E E C P @ G M A I L . C O M

2. PHENOMENOLOGY
Definitions
Intoxication
Addiction
Withdrawal
Tolerance
Physical
Dependence
Psychological
dependence
Substance
Dependence
Substance Abuse

3. INTOXICATION
Reversible substance-specific syndrome due to recent
ingestion of a substance .
Behavioral/psychological changes due to effects on CNS
developing after ingestion:
ex. Disturbances of perception, wakefulness, attention, thinking,
judgment, psychomotor behavior and interpersonal behavior.
Not due to another medical condition or mental disorder.
Does not apply to tobacco.

4. Substance
Dose
Route of
Administration
Duration/chronicity
Individual degree of
tolerance
Time since last dose
Person’s expectations
of substance effect
Contextual variables
CLINICAL PICTURE OF INTOXICATION DEPENDS ON:

5. WITHDRAWAL
1. Substance-specific syndrome problematic behavioral
change due to stopping or reducing prolonged use.
2. Physiological & cognitive components.
3. Significant distress in social, occupational or other
important areas of functioning.
4. Not due to another medical condition or mental disorder.

6. TOLERANCE
Need to use an increased amount of a substance
in order to achieve the desired effect
OR
Markedly diminished effect with continued use
of the same amount of the substance

7. PHYSICAL DEPENDENCE
A condition in which a person takes a drug over time, and
unpleasant physical symptoms occur if the drug is
suddenly stopped or taken in smaller doses.
The development of withdrawal symptoms once a drug is
stopped.
E.g. body pain, decrease appetite, seizure, etc.

8. PSYCHOLOGICAL DEPENDENCE
The term psychological dependence is generally meant
to describe the emotional and mental processes that are
associated with the development of, and recovery from, a
substance use disorder or process addiction.
Issues with anxiety that occur when someone tries to stop
their addictive behavior.

9. ADDICTION
Addiction is a complex condition, a brain disease that is
manifested by compulsive substance use despite harmful
consequence.
People with addiction (severe substance use disorder) have
an intense focus on using a certain substance(s), such as
alcohol or drugs, to the point that it takes over their life.

10. SUBSTANCE ABUSE
Substance abuse refers to the harmful or hazardous
use of psychoactive substances, including alcohol
and illicit drugs.

11. ABSTINENCE
Abstinence is a self-enforced restraint from
indulging in bodily activities that are widely
experienced as giving pleasure.

12. DSM-IV DEPENDENCE CRITERIA
 Tolerance
 Withdrawal
 Use in larger amounts or for longer than intended
 Desire to cut down or control use
 Great deal of time spent in obtaining substance
or getting over effects
 Social, occupational, or recreation activities
given up or reduced
 Use despite knowledge of physical or
psychological problem

13. MAJOR SUBSTANCES
Alcohol
Amphetamines and related
Caffeine
Cannabis
Cocaine
Hallucinogens
Inhalants
Nicotine
Opioids
Phencyclidine and related
Sedatives
Polysubstance Abuse

14. EPIDEMIOLOGY

15. SUBSTANCE USE
0
20
40
60
80
100
Alcohol
Caffeine
Tobacco
Illicit

16. ETIOLOGY OF SUBSTANCE ABUSE: GENETICS
1 parent:
20%
2 parents
20-50%
sons of father
50%
if severe alcoholic and criminal:
90% risk in son.

17. GENETICS
Twins
fraternal:28%
identical: 54%
Adopted
Danish Adoption Study (1974)
adopted sons of alcoholics raised by non-
alcoholic foster parents still had increased risk
of alcoholism.

18. WHY SOME COLLEGE STUDENTS USE
SUBSTANCE
1. Stress: As students are facing the high demands of coursework, part-time jobs,
internships, social obligations and more, many turn to drugs as a way to cope.
2. Course load: More students than ever are taking stimulants, such as Adderall, to
help them stay awake long enough to study or complete assignments by their due
dates. All too often, these prescription drugs are obtained without a legitimate
prescription.
3. Curiosity. College students are exploring many new aspects of their lives in
personal and professional realms. It’s not uncommon for that self-exploration to
dip into drug experimentation.
4. Peer pressure: College students who are surrounded by other people
experimenting with recreational and performance-enhancing drugs are more
likely to try these substances for themselves.

19. IMPACTS OF USING SUBSTANCE
Decreased Academic Performance
•Substance abuse causes grades to “slip”
because you're no longer able to keep up with
your studies and perform to the best of your
abilities.
•Drug and alcohol abuse might cause you to
stay in bed and miss exams because you have a
hangover or because you'd rather be partying
instead of going to class.
http://education.seattlepi.com/effects-drugs-alcohol-college-campuses-3031.html

20. IMPACTS OF USING ALCOHOL AND DRUGS
Physical and Psychological Impact
•On average, 1,825 college students between the ages of 18 to 24 die
each year due to alcohol-related injuries, according to the National
Institute on Alcohol Abuse and Alcoholism.
•However, alcohol and drugs don't have to kill you to have a serious
impact on your physical and psychological health:
• Alcohol and drugs damage your organs, cause brain dysfunction
and alter your perceptions, emotions and senses causing you to
take dangerous or unnecessary risks and even lead to mental
health disorders like depression.
• People who start using drugs or drinking during their college years
are more likely to develop a substance abuse problem later in life.

21. CONT….
Financial Impact
•Alcohol and substance abuse can also have a
negative financial impact on college students -
drugs and alcohol aren't usually free.
•Many college students are already financially
strapped, and making the choice to spend money
on drugs or alcohol might mean there's less money
available to buy books or even food.

22. CONT….
Legal Considerations
•College students who are under 21 and drink -- or those over
the age of 21 who supply minors with alcohol -- might be
subjected to disciplinary action, such as suspension, expulsion
or arrest.
•Illegal use of drugs and alcohol is a federal crime, so students
caught using illegal substances might be subjected to serious
legal consequences, depending on a number of factors, such as
the amount and type of drug or whether they were caught
selling or in possession of the drugs.

23. SUBSTANCE-INDUCED MENTAL
DISORDER
Potentially severe, usually temporary, but sometimes
persisting CNS syndromes .
Context of substances of abuse, medications, or
toxins.
Can be any of the 10 classes of substances

24. SUBSTANCE-INDUCED MENTAL DISORDER
Clinically significant presentation of a mental disorder
Not an independent mental disorder
 Preceded onset of use
 Persists for substantial time after use (which would not expect)

25. NEUROADAPTATION:
Refers to underlying CNS changes that occur following
repeated use such that person develops tolerance and/or
withdrawal
Pharmacokinetic – adaptation of metabolizing system
Pharmacodynamic – ability of CNS to function despite high
blood levels

26. COMORBIDITY
Up to 50% of addicts have comorbid psychiatric
disorder
Antisocial PD
Depression
Suicide

27. TYPICAL PRESENTATION AND
COURSE:
Present in acute intoxication, acute/chronic withdrawal or
substance induced mood, cognitive disorder or medical
complications.
Abstinence depends on several factors: social, environmental,
internal factors (presence of other comorbid psychiatric
illnesses).
Remission and relapses are the rule (just like any other chronic
medical illness).
Frequency, intensity and duration of treatment predicts
outcome 70 % eventually able to abstain or decrease use to
not meet criteria.

28. OPTIONS FOR WHERE TO TREAT
Hospitalization-
-Due to drug OD, risk of severe withdrawal, medical
comorbidities, requires restricted access to drugs,
psychiatric illness with suicidal ideation
Residential treatment unit
-No intensive medical/psychiatric monitoring needs
-Require a restricted environment
-Partial hospitalization
Outpatient Program -No risk of med/psych morbidity and
highly motivated patient

29. TREATMENT
Manage Intoxication & Withdrawal
Intoxication
Ranges: euphoria to life-threatening emergency
Detoxification
outpatient: "social detox” program
inpatient: close medical care
preparation for ongoing treatment

30. TREATMENT
Behavioral Interventions:
Motivation to change (MI)
Group Therapy
Individual Therapy
Contingency Management
Self-Help Recovery Groups (AA)
Therapeutic Communities
Aversion Therapies
Family Involvement/Therapy
Twelve-Step Facilitation
Relapse Prevention

31. TREATMENT
Pharmacologic Intervention
Treat Co-Occurring Psychiatric Disorders
50% will have another psychiatric disorder
Treat Associated Medical Conditions
cardiovascular, cancer, endocrine, hepatic, hematologic,
infectious, neurologic, nutritional, GI, pulmonary, renal,
musculoskeletal