Biopsychosocial and Diagnosis

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Susan W. Gray

Psychopathology: A Competency-Based Assessment Model for Social Workers

Chapter 14 Substance-Related and Addictive Disorders

These disorders are associated with a wide range of factors in a person’s life, including, for example, genetics, individual traits or temperament, gender, family history, sociocultural attitudes, and neighborhood consisting of:

Substance use disorder – combines (earlier) categories of substance abuse and dependence

Addiction is identified by a dimensional rating system from mild to severe based on severity

Substance-induced disorder - accompanied by the criteria for intoxication, and withdrawal

Substance/medication-induced mental disorders (eg.: psychotic disorders, depressive disorders, or anxiety disorders to list a few)

The non-substance-related disorders include gambling disorder

General Criteria for the Substance Use Disorders

The DSM-5 developed general criteria consisting of 11 symptoms that apply to the substance disorders seen as:

A maladaptive pattern leading to clinically significant impairment or distress for at least 12 months with features that must meet 2 or more of the following 11 symptoms grouped according to:

Impaired control

Social impairment

Risky use

Pharmacological criteria defined by:

Tolerance

Withdrawal – differs for each classification (excludes 3 substances)

And does not include medications taken under medical supervision

Specifiers are: severity, remission and in a controlled environment

Specific Symptoms of the Substance Use Disorders

Impaired Control – taking the substance in larger amounts and for longer than originally intended; unsuccessful efforts at cutting down despite a persistent desire to cut down (or discontinue use); spending time to use or obtain the substance or recovering from its effects; craving

Social Impairment – failure to fulfill major role obligations; recurrent substance use despite persistent or recurrent social or interpersonal problems; giving up or reducing other activities

Risky Use – continued use in situations that are physically hazardous; continuing use despite knowing of the problems caused

Tolerance* - needing an increased amount of the substance; significantly reduced effect

Withdrawal* – after prolonged use, stop using and develop symptoms (not documented for phencyclidine use disorder, other hallucinogen use, or inhalants)

* Both exclude medications taken under medical supervision

General Criteria for the Substance-Induced Disorders

…are categorized in the DSM according to the manifested effects of the substance on the individual and they are:

Substance intoxication—The occurrence of a reversible substance-specific syndrome due to recent ingestion or exposure to a substance (described for each substance class excluding tobacco)

Substance withdrawal—Shown as a problematic substance-specific behavior change with both physiological and cognitive elements that are due to stopping or attempting to cut down heavy and prolonged substance use

The Assessment for Substance Use

The assessment considers how a substance is taken including:

Route of administration (oral ingestion, inhalation, smoking, injection into the veins, “snorting”) and the speed of substance effects

Duration of effects

Use of multiple substances

Associated laboratory findings

The practitioner also considers problems in many aspects of people’s lives (such as family conflict, depression, anxiety, financial and/or legal difficulties to list a few)

Substance/Medication-Induced Mental Disorders

Each disorder is described in more detail in the relevant DSM classification and they are:

Psychotic disorders

Bipolar disorders

Depressive disorders

Anxiety disorders

Obsessive-Compulsive and related disorders

Sleep disorders

Sexual dysfunctions

Delirium

Neurocognitive disorders

Alcohol-Related Disorders

Alcohol use - the individual must meet 2 (or more) of the 11 overall criteria for substance use within a 12 month period

Intoxication - recent drinking and significant behavioral or psychological changes (such as inappropriate sexual or aggressive behavior, mood lability, impaired judgment, and problems in social or work interactions that developed during or shortly after alcohol ingestion); additionally, the person shows 1 (or more) of: slurred speech; lack of physical coordination; unsteady gait; nystagmus; impaired memory/attention; stupor or coma

Withdrawal - emerge after the person stops or reduces a heavy and prolonged pattern of drinking showing 2 (or more) symptoms of: autonomic hyperactivity; increased hand tremor; insomnia; nausea or vomiting; transient visual, tactile, or auditory hallucinations or illusions; agitation; anxiety; or/and generalized tonic-colonic (grand mal) seizures

The case of Chris Oghee features alcohol use

Long-term Effects of Alcohol Use

Korsakoff psychosis - which is a chronic memory disorder (and detailed in the chapter on the neurocognitive disorders)

Wernicke encephalopathy - an acute brain reaction to severe lack of thiamine

Social problems such as absenteeism from work, job-related accidents, and low employee productivity

Alcohol use is often associated with using (or abusing) other substances such as cannabis, cocaine, heroin, the amphetamines, sedatives, or nicotine increasing the risk for suicide, accidents, or violence

Caffeine-related Disorders

Caffeine intoxication – after consumption (typically high doses in excess of 250 mg.), 5 (or more) of must be present: restlessness; nervousness; excitement; insomnia; flushed face; diuresis; gastrointestinal disturbance; muscle twitching; rambling flow of thought and speech; tachycardia or cardiac arrhythmia; periods of inexhaustibility; or psychomotor agitation

Caffeine withdrawal – prolonged daily use with 3 (or more) of the following symptoms after stopping; headache; fatigue or drowsiness; depressed mood or irritability; difficulty concentrating; flu-like symptoms of nausea/vomiting and muscle pain/stiffness

Cannabis-related Disorders

Cannabis use - the individual must meet 2 (or more) of the 11 overall criteria for substance use within a 12 month period

Intoxication - behavioral or psychological changes (such as impaired coordination, euphoria, anxiety, a sensation of slowed time, impaired judgment, or social withdrawal) developing within 2 hours of use producing 2 (or more) symptoms of: bloodshot eyes; increased appetite; dry mouth; and tachycardia

Withdrawal – symptoms emerge after the person stops or reduces a heavy and prolonged pattern of use over at least a few months showing within about 1 week 3 (or more) symptoms of: irritability; nervousness or anxiety; sleep difficulties; decreased appetite or weight loss; restlessness; depressed mood; or uncomfortable physical symptoms such as stomach pain, shakiness or tremors, sweating, fever, chills, or a headache

Hallucinogen-related Disorders

Phencyclidine use - a class of hallucinogenic drugs using the general criteria for substance use where the individual must meet 2 (or more) of the overall criteria (excluding withdrawal) for substance use within a 12 month period

Phencyclidine intoxication – during or after recent use, clinically significant behavior or psychological changes (e.g., belligerence, assaultiveness, impulsiveness, unpredictability, agitation, impaired judgment, or impaired social or occupational functioning) develop, and within 1 hour, the user experiences 2 or more of the following symptoms: vertical or horizontal nystagmus; hypertension or tachycardia; numbness or diminished responsiveness to pain; ataxia; dysarthria (or slurred speech); muscle rigidity; seizures or coma; or hyperacusis (sensitivity to sound)

Hallucinogen-related Disorders

Other hallucinogen use - meet 2 (or more) of the overall diagnostic criteria (excluding withdrawal) for substance use within a 12 month period

Other hallucinogen intoxication – after recent use (excluding phencyclidine), clinically significant behavior or psychological changes (e.g., marked anxiety or depression, ideas of reference, a fear of losing one’s mind, paranoid ideas, or impaired judgment) along with perceptual changes are seen, and the user experiences 2 or more of the following symptoms: pupillary dilation; tachycardia; sweating; palpitations; blurred vision; tremors; and lack of coordination

Hallucinogen Persisting Perception Disorder

Commonly called flashbacks this disorder is the re-experiencing of perceptual disturbances, typically visual, when the drug experience has ended

The individual re-experiences 1 (or more) of the perceptual symptoms that were experienced while intoxicated such as geometric hallucinations; false perceptions of movement in the peripheral visual fields; flashes of color, intensified colors, trails of images of moving objects, positive afterimages, halos around objects; macropsia (where objects look larger than they actually are); and micropsia (like the rearview mirror in your car where objects look smaller than they are in reality) causing significant distress

Inhalant-related Disorders

Inhalant use – meet 2 (or more) of the same general criteria for the substance use disorders with the exception of withdrawal within a 12 month period

Inhalant intoxication - After a recent (or unintended) and short-term high dose of inhalant substances, clinically significant behavior or psychological changes (e.g., belligerence, assaultiveness, apathy, impaired judgment) are seen along with physical symptoms of intoxication that develop during or shortly after use which include 2 (or more) of the following: dizziness; nystagmus; lack of coordination; slurred speech; unsteady gait; lethargy; depressed reflexes; psychomotor retardation; tremor; generalized muscle weakness; blurred vision or diplopia (double vision); stupor or coma; and euphoria

Opioid-related Disorders

Opioid use - meet 2 (or more) of the general guidelines for the substance use disorders

Opioid intoxication - key elements are significant maladaptive behavior or psychological changes (such as euphoria followed by apathy, dysphoria, agitation or psychomotor retardation, impaired judgment, or impaired social or occupational functioning) that develop during or shortly after opioid use along with constricted pupils from severe use with 1 (or more) of the following: drowsiness or coma; slurred speech; and impairment in attention or memory

Opioid withdrawal - After stopping or reducing heavy and prolonged use, 3 (or more) of the following symptoms develop within minutes to days: severe dysphoria; nausea or vomiting; muscle aches or cramps; lacrimation or rhinorrea; dilated pupils, piloerection, or sweating; diarrhea; yawning; fever; or insomnia

Substance-related and Addictive Disorders

This review of substance-related and addictive disorders continues on the next series of Power Point slides