Substance-related disorders abuse

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. 

In DSM-IV parlance, psychiatric illnesses that result from substance use are called substance-related disorders. Within this broad spectrum are two distinct categories substance use disorders and snbstance-induced disorders. The substance use disorders consist of abusive patterns of nse that produce a myriad of problems in relationships, employment, medical or physical well-being, and legal matters. There is no predefined amount or frequency of substance use that defines these disorders instead, they are diagnosed when the consequences of substance use include an adverse impact on other areas of life. As noted earlier, in some instances, substance nse disorders lead to physical dependence that is manifested by tolerance and the potential for withdrawal symptoms. When anyone talks about addiction, it is typically snbstance nse disorders to which they refer. 

Substance-related disorders are divided in DSM-IV into dependence, abuse, intoxication, and withdrawal. In addition, each substance may have related disorders phenomenologically similar to other disorders delirium, dementia, amnestic, psychotic, mood, anxiety, sex, and sleep disorders. 

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. 

Substance abuse and related disorders represent a major problem area facing the clinician. Despite the "war on drugs" they continue to be a widespread problem. At least 5 percent of Americans are alcoholic, and stimulant abuse is a serious problem among teenagers and young adults. Any solution to these problems will undoubtedly involve social and political factors in addition to clinical programs. This chapter focuses on the differing types of clinical syndromes related to each commonly abused substance and medications that may be useful as an adjunct to treatment. 

Benzodiazepines have a low risk for abuse in anxiety disorder patients without a history of alcohol or other substance abuse. Among the benzodiazepines there may be a spectrum of abuse liability, with drugs that serve as prodrugs for desmethyldiazepam (e.g., clorazepate), slow-onset agents (e.g., oxazepam), and partial agonists (e.g., abecarnil) having the least potential for abuse. However, there is no currently marketed benzodiazepine or related drug that is free of potential for abuse. 

Numerous studies found that childhood sexual, physical, and emotional abuse also predisposes victims of such abuse to the development of depression in adulthood (e.g., McCauley et ah, 1997). The risk for depression increases with early onset and severity of the abuse as well as with the experience of multiple types of abuse. In addition, child abuse is related to an array of anxiety disorders, including generalized anxiety disorder and PTSD (e.g., Kendler et ah, 2000). Other disorders related to childhood abuse include substance abuse, eating disorders, dissociation, and so-... 

Personality disorders can complicate management (e.g., borderline disorder with a superimposed MDD). Dual depression occurs in patients who have chronic dysthymic disorder and then experience a superimposed MDD. Substance abuse and dependence are frequently co-morbid with mood disorders and substantially increase depression-related morbidity and mortality rates (see Drug-Induced Syndromes ). 

Older persons account for one-third of all suicides in the United States even though this group represents only 12% of the population ( 36). Suicide is even more often related to major depression in the elderly than in younger individuals in whom other causes such as substance abuse, bipolar disorder, schizophrenia, and personality disorders often play a major role. In fact, suicide rates are highest in older white men relative to any other segment of the population. For example, white men older than 85 years age commit suicide 30 times as frequently as black women. 

Finally, as noted earlier, comorbid substance abuse, particularly with bipolar male patients, is a strong predictor of suicide-related lethality. It is critically important to recognize these complicating disorders and aggressively intervene with appropriate clinical strategies. Referral to Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and other related counseling support programs, as well as prescription of naltrexone (Revia) in the appropriate patients, may also help to diminish the risk of serious morbidity (see also the section The Alcoholic Patient in Chapter 14). 

Secondary insomnia related to a known organic factor may occur in conjunction with a physical illness (but not the person s emotional reaction to the illness), psychoactive substance abuse, or certain medications. Secondary insomnia may also be related to another mental disorder. 

An important related problem is the trend toward demedicalization of state mental health facilities. Given a host of clinical and economic realities, many HIV-infected patients can only be served by such institutions ( 472). Their complicated psychiatric and medical presentations, however, require a high level of clinical sophistication, particularly in recognizing and managing their physical co-morbidities ( 473, 474). Indeed, an increasing number of patients suffer from a triple diagnosis (i.e., a psychiatric disorder with co-morbid substance abuse and HIV-positive status) ( 475). 

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