Substance-induced

Glassification of Substance-Related Disorders. The DSM-IV classification system (1) divides substance-related disorders into two categories (/) substance use disorders, ie, abuse and dependence and (2) substance-induced disorders, intoxication, withdrawal, delirium, persisting dementia, persisting amnestic disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. The different classes of substances addressed herein are alcohol, amphetamines, caffeine, caimabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, hypnotics or anxiolytics, polysubstance, and others. On the basis of their significant socioeconomic impact, alcohol, nicotine, cocaine, and opioids have been selected for discussion herein. 

Uncomplicated, with delirium, with delusions, and with depressed mood Dementia due to HIV disease Dementia due to head trauma Dementia due to Parkinson s disease Dementia due to Huntington s disease Dementia due to Pick s disease Dementia due to Creutzfeldt-Jakob disease Dementia due to a specific general medical condition (specify) Dementia that is substance-induced Dementia due to multiple etiologies Dementia not otherwise specified... 

Boutros NN and Bowers MB (1996). Chronic substance-induced psychotic disorders State of the literature. Journal of Neuropsychiatry and Clinical Neurosciences, 8, 262-269. 

Avery, O. T., MacLeod, C. M. and McCarty, M. (1944), Studies on the chemical nature of the substance inducing transformation of Pneumococcal types induction of transformation by a deoxyribonucleic acid fraction isolated from Pneumococcus IIP, Journal of Experimental Medicine, 79, 137-157. 

The disorder is not caused by a medical condition (eg., hypothyroidism) or substance-induced disorder (eg., antidepressant treatment, medications, electroconvulsive therapy). 

The mood disorders were once called affective disorders and are grouped into two main categories unipolar and bipolar. The unipolar depressive disorders include major depressive disorder and dysthymic disorder the bipolar disorders include bipolar 1, bipolar II, bipolar not otherwise specified, and cyclothymic disorder. Other mood disorders are substance-induced mood disorders and mood disorders due to a general medical condition. In addition, mood disturbance commonly occurs as a symptom in other psychiatric disorders including dementia, post-traumatic stress disorder, substance abuse disorders, and schizophrenia. 

The unipolar mood disorders consist solely of episodes of depression. On the other hand, the bipolar mood disorders consist of episodes of both depressed and elevated mood. The periods of elevated mood are characterized by either euphoria or irritability and are called mania or hypomania depending on the level of severity. A schematic of the mood disorders is shown in Figure 3.1. Substance-induced mood disorders and mood disorders due to general medical conditions usually manifest depressed mood however, manic episodes are occasionally seen as well. 

The cause of most psychiatric disorders including depression remains unknown nevertheless, some diagnostic considerations are based on presumed causative factors. In these cases, the distinction from major depression is not based on the symptomatic presentation because there may be no symptomatic difference. The difference lies in the presence of an identifiable biological factor that is presumably causing the depressive syndrome. The causative differential of MDD includes a mood disorder due to a general medical condition in medically ill patients and a substance-induced mood disorder in patients using certain medications or substances of abuse. A comprehensive evaluation of depression must include consideration of potentially treatable causative factors. 

Substance-Induced Mood Disorder. Many prescription medications and abused substances cause depression (see Table 3.5). This idea is not new. In fact, recognizing that certain medications cause depression has helped us to understand the biology of depression better. 

Depression caused by a substance is usually indistinguishable from major depression. It s seldom that a substance-induced mood disorder can be diagnosed with absolute certainty. However, when your patient becomes depressed shortly after beginning to use a medication known to cause depression in others, it s reasonable to assume that the substance may be causing your patient s depression. 

Substance-induced Psychotic Disorder. Nearly every psychiatrist has had the... 

Substance-Induced Anxiety Disorder. Numerous medicines and drugs of abuse can produce panic attacks. Panic attacks can be triggered by central nervous system stimulants such as cocaine, methamphetamine, caffeine, over-the-counter herbal stimulants such as ephedra, or any of the medications commonly used to treat narcolepsy and ADHD, including psychostimulants and modafinil. Thyroid supplementation with thyroxine (Synthroid) or triiodothyronine (Cytomel) can rarely produce panic attacks. Abrupt withdrawal from central nervous system depressants such as alcohol, barbiturates, and benzodiazepines can cause panic attacks as well. This can be especially problematic with short-acting benzodiazepines such as alprazolam (Xanax), which is an effective treatment for panic disorder but which has been associated with between dose withdrawal symptoms. 

Primary care physicians are critical to the successful identification of GAD. Characterized by often-vague physical complaints, GAD must be distinguished from medical illnesses and other psychiatric disorders, though the high rate of comorbidity requires that a thorough evaluation for GAD be completed even when another disorder has been identified. GAD warrants particular consideration for those patients with nonspecific physical complaints who nevertheless have an urgent need for relief that has resulted in repeated office visits. The differential diagnosis for GAD includes other anxiety disorders, depression, and a variety of medical conditions and substance-induced syndromes. 

In this chapter, we will focus primarily on treatments for the substance use disorders. However, because detoxification during a substance-induced withdrawal is often the first step in treating a substance use disorder, we will discuss withdrawal states to some extent. The substance use disorders include both substance abuse and the more serious substance dependence. Substance abuse consists of a pattern of misuse that causes recurring problems in at least one aspect of life. This can be a failure to fulfill responsibilities at home or work, reckless use of the substance such as drunken driving, repeated substance-related arrests, and ongoing substance use despite resulting problems in family relationships. See Table 6.1 for the diagnostic criteria for substance abuse. 

Laboratory testing should be used to complete the assessment and includes urine drug screens, as well as general medical screening tests to rule out underlying substance-induced medical illness. The specific tests vary somewhat depending on the substance that is being abused. 

Substance-Induced Insomnia. A variety of substances can cause or worsen sleep problems (see Table 9.2). Patients often miss the connection between the ingestion of a medication or caffeine and the onset of their insomnia, and they rarely spontaneously volunteer this information. 

Substance-Induced Dementias. Substances of abuse can also cause dementia. The most common is alcohol-related dementia. Chronic alcoholism leads to dementia in several ways. The poor diet of the alcoholic causes a deficiency of certain essential nutrients such as thiamine. The alcoholic often suffers recurrent head injuries from falls or altercations. Alcohol-induced liver failure can expose the brain to toxic injury. Finally, the direct toxic effects of alcohol itself on the brain can lead to dementia. In addition to alcohol, the abuse of inhalants such as paint thinner and... 

Experience has shown that it is difficult to obtain useful data on substance-induced eye irritation (EC 2003). 

Autoimmune diseases are another important area of substance-induced immunotoxicity. At present there are no specific assays to assess substances for their potential to induce autoimmune reactions (EC 2003). 

Positive results in the mammalian in vivo bone marrow chromosome aberration test indicate that a substance induces stmctural chromosome aberrations in the bone marrow of the species tested. An increase in polyploidy (a multiple of the haploid chromosome number (n) other than the diploid number, i.e., 3n, 4n and so on) may indicate that a substance has the potential to induce numerical aberrations (change in the number of chromosomes from the normal number characteristic of the animals utilized). 

Positive results in the in vivo mammalian spermatogonial chromosome aberration test indicate that a substance induces structural chromosome aberrations in the germ cells of the species tested. This test measures chromosome events in spermatogonial germ cells and is, therefore, expected to be predictive of induction of inheritable mutations in germ cells. 

Positive results in the Mouse Biochemical Specific Locus Test (MBSL) and/or in the Mouse Visible Specific Locus Test (MSLT) indicate that the test substance induces heritable gene mutations in a mammahan species. 

Positive results in the in vivo sister chromatid exchange (SCE) assay indicate that the test substance induces reciprocal chromatid interchanges in the bone marrow or lymphocytes of the test species. SCEs represent the interchange of DNA replication products at apparently homologous loci. The exchange process presumably involves DNA breakage and reunion, although httle is known about its molecular basis. 

Positive results from the bacterial reverse mutation test (often referred to as the Ames test) indicate that a substance induces point mutations by base pair substimtion or frameshift in the... 

Positive results from the in vitro chromosome aberration test indicate that the test substance induces structural chromosome aberrations in culmred mammalian somatic cells. More details about this endpoint are provided under the in vivo tests. 

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