Substance abuse is as common as it is costly to society. It is etiologic for many medical illnesses and is frequently comorbid with psychiatric illness. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) defines substance abuse and dependence independent of the substance.
Hence, alcohol abuse and dependence is defined by the same criteria as heroin abuse and dependence. This section defines abuse and dependence and provides clinical descriptions of each substance-related disorder. The DSM-IV recognizes the different signs and symptoms associated with various drug addictions.
We review the common substance-related disorders in sequence.
- Alcohol and Alcoholism: Introduction
- The Effects of Ethanol on Organ Systems
- Alcoholism (Alcohol Abuse or Dependence)
- Identification of the Alcoholic and Intervention
- Rehabilitation of Alcoholics
- The Alcohol Withdrawal Syndrome
- Cocaine and Other Commonly Abused Drugs
- Marijuana and Cannabis Compounds
- Lysergic Acid Diethylamide (LSD)
- Polydrug Abuse
- Nicotine Addiction: Introduction
- Disease Manifestations of Cigarette Smoking
- Nicotine Addiction: Pharmacologic Interactions
- Other Forms of Tobacco Use
- Lower Tar and Nicotine Cigarettes
- Nicotine Addiction: Cessation
- Nicotine Addiction: Physician Intervention
- Nicotine Addiction: Prevention
- Opioid Drug Abuse and Dependence: Introduction
- Opioid Drug Abuse and Dependence
- Acute and Chronic Effects of Opioids
The Diagnostic Criteria of Substance-Induced Disorders
According to the mental health clinician's handbook, Diagnostic and Statistical Manual of Mental Disorders (the DSM ), fourth edition text revised ( DSMIV-TR ), all of the substances listed above, with the exceptions of nicotine and caffeine, have disorders of two types: substance use disorders and substance-induced disorders. Substance use disorders include abuse and dependence. Substance-induced disorders include intoxication, withdrawal, and various mental states ( dementia , psychosis , anxiety, mood disorder, etc.) that the substance induces when it is used.
Substance dependence is characterized by continued use of a substance even after the user has experienced serious substance-related problems. The dependent user desires the substance ("craving") and needs more of the substance to achieve the effect that a lesser amount of the substance induced in the past. This phenomenon is known as tolerance. The dependent user also experiences withdrawal symptoms when the substance is not used. Withdrawal symptoms vary with the substance, but some symptoms may include increased heart rate, shaking, insomnia , fatigue , and irritability.
Substance abuse is continued use of a substance in spite of school- or work-related or interpersonal problems, but the user has not gotten dependent on the substance. The individual who abuses a substance may experience legal problems and may have problems fulfilling responsibilities, such as caring for a child.
Intoxication is the direct effect of the substance after an individual has used or has been exposed to the substance. Different substances affect individuals in various ways, but some of the effects seen in intoxication might include impaired judgment, emotional instability, increase or decrease in appetite, or changed sleep patterns.
A common and serious mental disorder characterized by loss of contact with reality (psychosis), hallucinations (false perceptions), delusions (false beliefs), abnormal thinking
Alcohol intoxication is defined by the presence of slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, stupor or coma, and clinically significant maladaptive behavioral or psychological changes (inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that develop during or shortly after alcohol ingestion.
The diagnosis of alcohol intoxication must be differentiated from other medical or neurologic states that may mimic intoxication, for example, diabetic hypoglycemia; toxicity with various agents, including but not limited to ethylene glycol, lithium, and phenytoin; and intoxication with benzodiazepines or barbiturates.
Opiates include morphine, heroin, codeine, meperidine, and hydromorphone. Heroin is only available illegally in the United States. Opiates are commonly used for pain control.
Opiate use and abuse are relatively uncommon in the United States. Lifetime prevalence in 1991 was 0.9% and point prevalence was less than 0.1 %, although more recent surveys indicate opiate use and abuse has been increasing during the past decade. Many of those who use opiates recreationally become addicted. The number of opiate addicts in the United States is estimated at 500,000.
Cannabis is widely used throughout the world in the forms of marijuana and hashish. The drug is usually smoked and causes a state of euphoria. Complications of cannabis include impaired judgement, poor concentration, and poor memory. Serious complications include delirium and/or psychosis.
Club Drugs are a group of drugs classified by the National Institute on Drug Abuse (NIDA) according to their popularity in dance clubs and other party venues. These drugs are of a wide variety of chemical classes, but are linked by their frequent use in social groups and the fact that they are commonly taken together. Because of their popularity and tendency for users to show up in emergency rooms, we review some of the more widely used Club Drugs below.
As defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (American Psychiatric Association [APA] 2000) (DSM-IV-TR), substance-induced disorders include:
- Substance-induced delirium
- Substance-induced persisting dementia
- Substance-induced persisting amnestic disorder
- Substance-induced psychotic disorder
- Substance-induced mood disorder
- Substance-induced anxiety disorder
- Hallucinogen persisting perceptual disorder
- Substance-induced sexual dysfunction
- Substance-induced sleep disorder
Substance-induced disorders are distinct from independent co-occurring mental disorders in that all or most of the psychiatric symptoms are the direct result of substance use. This is not to state that substance-induced disorders preclude co-occurring mental disorders, only that the specific symptom cluster at a specific point in time is more likely the result of substance use, abuse, intoxication, or withdrawal than of underlying mental illness. A client might even have both independent and substance-induced mental disorders. For example, a client may present with well-established independent and controlled bipolar disorder and alcohol dependence in remission, but the same client could be experiencing amphetamine-induced auditory hallucinations and paranoia from an amphetamine abuse relapse over the last 3 weeks.
Symptoms of substance-induced disorders run the gamut from mild anxiety and depression (these are the most common across all substances) to full-blown manic and other psychotic reactions (much less common). The "teeter-totter principle" - i.e., what goes up must come down - is useful to predict what kind of syndrome or symptoms might be caused by what substances. For example, acute withdrawal symptoms from physiological depressants such as alcohol and benzodiazepines are hyperactivity, elevated blood pressure, agitation, and anxiety (i.e., the shakes). On the other hand, those who "crash" from stimulants are tired, withdrawn, and depressed. Virtually any substance taken in very large quantities over a long enough period can lead to a psychotic state.
Because clients vary greatly in how they respond to both intoxication and withdrawal given the same exposure to the same substance, and also because different substances may be taken at the same time, prediction of any particular substance-related syndrome has its limits. What is most important is to continue to evaluate psychiatric symptoms and their relationship to abstinence or ongoing substance abuse over time. Most substance-induced symptoms begin to improve within hours or days after substance use has stopped. Notable exceptions to this are psychotic symptoms caused by heavy and long-term amphetamine abuse and the dementia (problems with memory, concentration, and problem solving) caused by using substances directly toxic to the brain, which most commonly include alcohol, inhalants like gasoline, and again amphetamines. Following is an overview of the most common classes of substances of abuse and the accompanying psychiatric symptoms seen in intoxication, withdrawal, or chronic use.
In most people, moderate to heavy consumption is associated with euphoria, mood lability, decreased impulse control, and increased social confidence (i.e., getting high). Such symptoms might even appear "hypomanic." However these often are followed with next-day mild fatigue, nausea, and dysphoria (i.e., a hangover). In a person who has many life stresses, losses, and struggles, which is often the case as addiction to alcohol proceeds, the mood lability and lowered impulse control can lead to increased rates of violence toward others and self. Prolonged drinking increases the incidence of dysphoria, anxiety, and such violence potential. Symptoms of alcohol withdrawal include agitation, anxiety, tremor, malaise, hyperreflexia (exaggeration of reflexes), mild tachycardia (rapid heart beat), increasing blood pressure, sweating, insomnia, nausea or vomiting, and perceptual distortions.
Following acute withdrawal (a few days), some people will experience continued mood instability, fatigue, insomnia, reduced sexual interest, and hostility for weeks, so called "protracted withdrawal." Differentiating protracted withdrawal from a major depression or anxiety disorder is often difficult. More severe withdrawal is characterized by severe instability in vital signs, agitation, hallucinations, delusions, and often seizures. The best predictor of whether this type of withdrawal may happen again is if it happened before. Alcohol-induced deliriums after high-dose drinking are characterized by fluctuating mental status, confusion, and disorientation and are reversible once both alcohol and its withdrawal symptoms are gone, while by definition, alcohol dementias are associated with brain damage and are not entirely reversible even with sobriety.
When consumed in large quantities, caffeine can cause mild to moderate anxiety, though the amount of caffeine that leads to anxiety varies. Caffeine is also associated with an increase in the number of panic attacks in individuals who are predisposed to them.
Cocaine and Amphetamines
Mild to moderate intoxication from cocaine, methamphetamine, or other stimulants is associated with euphoria, and a sense of internal well-being, and perceived increased powers of thought, strength, and accomplishment. In fact, low to moderate doses of amphetamines may actually increase certain test-taking skills temporarily in those with attention deficit disorders (see this in appendix D) and even in people who do not have attention deficit disorders. However, as more substance is used and intoxication increases, attention, ability to concentrate, and function decrease.
With street cocaine and methamphetamines, dosing is almost always beyond the functional window. As dosage increases, the chances of impulsive dangerous behaviors, which may involve violence, promiscuous sexual activity, and others, also increases. Many who become chronic heavy users go on to experience temporary paranoid delusional states. As mentioned above, with methamphetamines, these psychotic states may last for weeks, months, and even years. Unlike schizophrenic psychotic states, the client experiencing a paranoid state induced by cocaine more likely has intact abstract reasoning and linear thinking and the delusions are more likely paranoid and less bizarre (Mendoza and Miller 1992). After intoxication comes a crash in which the person is desperately fatigued, depressed, and often craves more stimulant to relieve these withdrawal symptoms. This dynamic is why it is thought that people who abuse stimulants often go on week- or month-long binges and have a hard time stopping. At some point the ability of stimulants to push the person back into a high is lost (probably through washing out of neurotransmitters), and then a serious crash ensues.
Even with several weeks of abstinence, many people who are addicted to stimulants report a dysphoric state that is marked by anhedonia (absence of pleasure) and/or anxiety, but which may not meet the symptom severity criteria to qualify as DSM-IV Major Depression (Rounsaville et al. 1991). These anhedonic states can persist for weeks. As mentioned above, heavy, long-term amphetamine use appears to cause long-term changes in the functional structure of the brain, and this is accompanied by long-term problems with concentration, memory, and, at times, psychotic symptoms. Month-long methamphetamine binges followed by week- or month-long alcohol binges, a not uncommon pattern, might appear to be "bipolar" disorder if the drug use is not discovered. For more information, see the National Institute on Drug Abuse Web site (www.nida.nih.gov).
Hallucinogens produce visual distortions and frank hallucinations. Some people who use hallucinogens experience a marked distortion of their sense of time and feelings of depersonalization. Hallucinogens may also be associated with drug-induced panic, paranoia, and even delusional states in addition to the hallucinations. Hallucinogen hallucinations usually are more visual (e.g., enhanced colors and shapes) as compared to schizophrenic-type hallucinations, which tend to be more auditory (e.g., voices). The existence of a marijuana-induced psychotic state has been debated (Gruber and Pope 1994), although a review of the research suggests that there is no such entity. A few people who use hallucinogens experience chronic reactions, involving prolonged psychotic reactions, depression, exacerbations of preexisting mental disorders, and flashbacks. The latter are symptoms that occur after one or more psychedelic "trips" and consist of flashes of light and after-image prolongation in the periphery. The DSM-IV defines flashbacks as a "hallucinogen persisting perception disorder." A diagnosis requires that they be distressing or impairing to the client (APA 1994, p. 234).
Clients who are dependent on nicotine are more likely to experience depression than people who are not addicted to it; however, it is unclear how much this is cause or effect. In some cases, the client may use nicotine to regulate mood. Whether there is a causal relationship between nicotine use and the symptoms of depression remains to be seen. At present, it can be said that many persons who quit smoking do experience both craving and depressive symptoms to varying degrees, which are relieved by resumption of nicotine use (see chapter 8 for more information on nicotine dependence).
Opioid intoxication is characterized by intense euphoria and well-being. Withdrawal results in agitation, severe body aches, gastrointestinal symptoms, dysphoria, and craving to use more opioids. Symptoms during withdrawal vary - some will become acutely anxious and agitated, while others will experience depression and anhedonia. Even with abstinence, anxiety, depression, and sleep disturbance can persist for weeks as a protracted withdrawal syndrome. Again, differentiating this from major depression or anxiety is difficult and many clinicians may just treat the ongoing symptom cluster. For many people who become opioid dependent, and then try abstinence, these ongoing withdrawal symptoms are so powerful that relapse occurs even with the best of treatments and client motivation. For these clients, opioid replacement therapy (methadone, suboxone, etc.) becomes necessary and many times life saving. There are reports of an atypical opioid withdrawal syndrome characterized by delirium after abrupt cessation of methadone (Levinson et al. 1995). Such clients do not appear to have the autonomic symptoms typically seen in opioid withdrawal. Long-term use of opioids is commonly associated with moderate to severe depression.
Phencyclidine (PCP) causes dissociative and delusional symptoms, and may lead to violent behavior and amnesia of the intoxication. Zukin and Zukin (1992) report that people who use PCP and who exhibit an acute psychotic state with PCP are more likely to experience another with repeated use.
Acute intoxication with sedatives like diazepam is similar to what is experienced with alcohol. Withdrawal symptoms are also similar to alcohol and include mood instability with anxiety and/or depression, sleep disturbance, autonomic hyperactivity, tremor, nausea or vomiting, and, in more severe cases, transient hallucinations or illusions and grand mal seizures. There are reports of a protracted withdrawal syndrome characterized by anxiety, depression, paresthesias, perceptual distortions, muscle pain and twitching, tinnitus, dizziness, headache, derealization and depersonalization, and impaired concentration. Most symptoms resolve within weeks, though some symptoms, such as anxiety, depression, tinnitus (ringing in the ears), and paresthesias (sensations such as prickling, burning, etc.), have been reported to last a year or more after withdrawal in rare cases. No chronic dementia-type syndromes have been characterized with chronic use; however, many people who use sedatives chronically seem to experience difficulty with anxiety symptoms, which respond poorly to other anxiety treatments.