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Chapter 14
Substance-Related and Impulse-Control
Disorders
DSM-5 Proposal

Combine the substance-related and impulsecontrol disorders into one new category,
addiction and related disorders.
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Substance Abuse

A substance is any natural or synthesized
product that has psychoactive effects—it
changes perceptions, thoughts, emotions,
and behaviors.
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In the United States, ethnic and age
groups have different rates of drug use
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The rate of illegal drug use by young adults
has fluctuated over time
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Substance-Related Conditions Recognized by
the DSM-IV-TR
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Substance intoxication: Experience of significant
maladaptive behavioral and psychological
symptoms due to the effect of a substance on the
central nervous system.
Substance withdrawal: Experience of clinical
significant distress in social, occupational, or other
areas of functioning due to the cessation or
reduction of substance use.
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Substance-Related Conditions Recognized by
the DSM-IV-TR, continued


Substance abuse: Diagnosis given when recurrent
substance use leads to significant harmful
consequences.
Substance dependence: Diagnosis given when
substance use leads to physiological dependence or
significant impairment or distress.
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Five categories of abused substances

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(1) central nervous system depressants, including
alcohol, barbiturates, benzodiazepines, and
inhalants
(2) central nervous system stimulants, including
cocaine, amphetamines, nicotine, and caffeine
(3) opioids, including heroin and morphine
(4) hallucinogens and phencyclidine (PCP)
(5) cannabis
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Chapter 14
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DSM-IV-TR Criteria for Substance Abuse
One or more of the following occurs during a 12month period, leading to significant impairment or
distress:

1.
2.
3.
4.
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Failure to fulfill important obligations at work, home, or
school as a result of substance abuse.
Repeated use of the substance in situations in which it
is physically hazardous to do so.
Repeated legal problems as a result of substance use.
Confirmed use of the substance despite repeated social
or legal problems as a result of use.
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DSM-IV-TR Criteria for Substance
Dependence
Maladaptive pattern of substance use, leading to
three or more of the following:
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
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Tolerance, as defined by either the need for markedly
increased amounts of the substance to achieve intoxication or
desired effect; markedly diminished effect with continued use
of the same amount.
Withdrawal, as manifested by either: the characteristic
withdrawal syndrome for the substance; the same or closely
related substance is taken to relieve or avoid withdrawal
symptoms.
The substance is often taken in larger amounts or over a
longer period than was intended.
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DSM-IV-TR Criteria for Substance
Dependence, continued


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Persistent desire or unsuccessful efforts to cut back or control
use.
A great deal of time is spent in activities necessary to obtain
the substance, use the substance, or recover from its effects.
Important social, occupational, or recreational activities are
given up or reduced because of substance use.
The substance use is continued despite knowledge of having
a persistent or recurrent physical or psychological problem
caused or exacerbated by the substance.
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DSM-5 Proposal


Substance abuse and dependence may be
combined in one diagnosis to be called substanceuse disorder.
Diagnostic criteria for substance-use disorder will
include:



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continued use of substances despite negative social,
occupational, and health consequences
evidence of tolerance or withdrawal.
“Craving the substance” will be added because it is
a common symptom of abuse/dependence
“Legal problems” will be removed from the criteria
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14
Depressants


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Depressants slow the central nervous
system.
In moderate doses, they make people
relaxed and somewhat sleepy, reduce
concentration, and impair thinking and motor
skills.
Includes alcohol, benzodiazepines,
barbiturates, and inhalants.
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Alcohol




Alcohol abuse
Alcohol dependence
Binge drinking
Withdrawal
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Long-term Effects of Alcohol Abuse
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Low-grade hypertension
Alcohol-induced persisting amnesic disorder
Wernicke’s encephalopathy
Korsakoff’s pyschosis
Alcohol-induced dementia
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Cultural Differences in Alcohol Disorders
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Ethnic Differences in Alcohol Use in the
United States
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Gender Differences
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Benzodiazepines and Barbiturates


Benzodiazepines (such as Xanax, Valium,
Halcion, and Librium) and barbiturates (such as
Quaalude) are legally manufactured and sold by
prescription, usually for the treatment of anxiety
and insomnia.
Two common patterns of abuse can develop with
these substances:


1. adolescents using them for recreational purposes
2. people (particularly women) using initially under
physician’s care but then increasing doses as
tolerance develops
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Inhalants

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Inhalants: solvents such as gasoline, glue, paint
thinners, and spray paints.
Greatest users of inhalants are young boys between
10 and 15 years of age.
Chronic users may have a variety of respiratory
irritations and rashes.
Can also cause permanent damage to the central
nervous system, and can lead to organ failure and
death.
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Stimulants

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Activate the central nervous system, causing feelings of energy,
happiness, and power, a decreased desire for sleep, and a
diminished appetite
Include cocaine and the amphetamines (including the related
drugs methamphetamines)
 Impart a psychological lift or rush
 Cause dangerous increases in blood pressure and heart rate,
alter the rhythm and electrical activity of the heart, and constrict
the blood vessels, which can lead to heart attacks, respiratory
arrest, and seizures
Caffeine and nicotine
Prescription stimulants, including Dexedrine and Ritalin
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Stimulants: Cocaine

Symptoms include:
–
–
–
–
–
–
behavioral changes (e.g., euphoria or affective
blunting; impaired judgment)
rapid heartbeat, dilation of pupils, elevated or
lowered blood pressure
weight loss, nausea or vomiting
muscular weakness
slowed breathing, chest pain, confusion
seizures, coma
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Stimulants: Amphetamines
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Used to combat depression or fatigue or boost
energy and self-confidence; also in diet drugs
Cause the release of dopamine and
norepinephrine and clock reuptake
Symptoms of intoxication are similar to cocaine
intoxication
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Stimulants: Nicotine
•
•
No DSM-IV-TR diagnosis for the symptoms, but
nicotine operates on both the central and
peripheral nervous system
Results in the release of several biochemicals
that may have direct reinforcing effects on the
brain, including dopamine, norepinephrine,
serotonin, and the endogenous opioids
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Stimulants: Nicotine, continued
• Withdrawal Symptoms
•
•
•
•
•
•
•
•
•
dysphoria or depressed mood
insomnia
irritability
frustration or anger
anxiety
difficulty concentrating
restlessness
decreased heart rate
increased appetite or weight gain
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Stimulants: Caffeine
•
•
•
•
The most heavily used stimulant drug
75% of caffeine ingested through coffee
The average American drinks about two cups of
coffee per day; a cup of brewed coffee has about
100 milligrams of caffeine
Caffeine stimulates the central nervous system
increasing levels of dopamine, norepinephrine,
and serotonin
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Stimulants: Caffeine, continued
•
•
Symptoms: Restlessness, nervousness,
excitement, insomnia, flushed face, frequent
urination, stomach upset, muscle twitching,
rambling flow of thought or speech, rapid
heartbeat, periods of inexhaustibility,
psychomotor agitation
Withdrawal Symptoms: Marked fatigue or
drowsiness, increased appetite or weight gain,
marked anxiety or depression, nausea or
vomiting
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Opioids- derived from the opium
poppy
• Morphine
• Heroin
• Codeine
• Methadone
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Hallucinogens and PCP


Hallucinogens are a mixed group of substances
including LSD, MDMA (also called ecstasy), and
peyote.
PCP, also known as angel dust, is a manufactured
as a powder to be snorted or smoked. Although not
classified as a hallucinogen, it has many of the
same effects.
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Cannabis
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The leaves of the cannabis (or hemp) plant can be cut, dried,
and rolled into cigarettes or inserted into food and beverages. In
North America, the result is known as marijuana, weed, pot,
grass, reefer, and Mary Jane
Cannabis is the most commonly used illegal drug in the United
States, with about 40% of the population reporting use of it at
some time in their lives, and 6% in the last month
About 7% of the population would qualify for a diagnosis of
cannabis abuse, and 2 to 3% for a diagnosis of cannabis
dependence
Occasional use is widespread: 30% of college students say they
have used cannabis in the last year
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Theories of Substance Use, Abuse, and
Dependence
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
These substances affect several
biochemicals that can have direct reinforcing
effects on the brain.
The brain appears to have its own “pleasure
pathway” that affects our experience of
reward
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BRAIN MAP SHOWINGSEPTAL/HIPPOCAMPAL
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Biological Theories

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Genetic Factors
 Family history, adoption, and twin studies all suggest that
genetics may play a substantial role in at least some forms of
addiction.
Reward Sensitivity

Substantial individual differences in sensitivity to the rewarding
properties of substances.
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Psychological Theories
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Social-learning theories: Children and adolescents
learn alcohol-related behaviors from the modeling of
their parents and important others in their culture.
Cognitive theories: focus on people’s expectations of
its effects and their beliefs about the appropriateness
of using it to cope with stress.
Personality characteristic of behavioral under
control: the tendency to be impulsive, sensationseeking, and prone to antisocial behaviors such as
violating laws.
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Sociocultural Approaches


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Chronic stress combined with an environment that
supports and even promotes the use of substances
as an escape is a recipe for widespread substance
abuse and dependence.
Substance use, particularly alcohol use, is much
more acceptable for men than for women in many
societies.
When women do become substance abusers, their
patterns of use and reasons for use tend to differ
from men’s.
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42
Treatments for Substance-Related
Disorders

Biological Treatments
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Medications, including antianxiety drugs, antidepressants,
and antagonists
Methadone Maintenance Programs
Behavioral and Cognitive Treatments
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Aversive classical conditioning
Covert sensitization therapy
Contingency management programs
Cognitive treatments
Motivational interviewing
Relapse prevention
Alcoholics Anonymous
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Impulse-Control Disorders
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Include kleptomania, pyromania, pathological gambling,
intermittent explosive disorder, and trichotillomania
People with these disorders often feel a mounting sense of
tension relieved only by engaging in their impulsive act
Some researchers consider these disorders to be similar to
substance-related disorders, and due to abnormalities in reward
systems in the brain
Others consider them to be part of the obsessive-compulsive
disorder continuum
DSM-5 authors have proposed moving these disorders to various
categories depending on the available research for each disorder
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