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Substance Related Disorders
Alcohol – Hallucinogen
Candace McBride
PSY6670
Troy University
Substance Related Disorders
Substance refers to a drug of abuse, a
medication, or a toxin.
Substances in the DSM are grouped into 11
classes:
Alcohol
Amphetamine
Caffeine
Cannabis
Cocaine
Hallucinogens
Substance Related Disorders
Substance Related Disorders are divided
into two categories:
Substance Use Disorders
(Dependence and Abuse)
Substance Induced Disorders
(Intoxication and Withdrawal)
Substance Dependence
Dependence is defined as cluster of three or more of the following
symptoms occurring at any time in a 12 month period.
Tolerance-a need for increased amounts of the substance or
diminished effect with the continued use of the same amount of the
substance.
Withdrawal-varies based on substance
There is a persistent desire or unsuccessful attempts to control
substance.
Substance is taken in larger amounts over a longer period of time.
A great deal of time is spent trying to obtain the substance.
Important social, occupational, or recreational activities are given up
or reduced because of the substance.
Substance Abuse
Abuse is defined as a maladaptive pattern of
substance use leading to clinically significant
impairment as demonstrated by one of the
following:
Failure to fulfill major role obligations at
work, school, or home.
Use in situations in which it is physically
hazardous
Recurrent substance related legal problems
Persistent social or interpersonal problems
caused by the effects of the substance.
Substance Intoxication
The reversible substance-specific
syndrome due to the recent ingestion of a
substance.
 Clinically significant behavior changes that
are due to the effect of the substance of
the nervous system, which include
belligerence, impaired judgment, or
impaired social functioning.

Substance Withdrawal
Development of a substance specific maladaptive
behavioral change due to the cessation of, or reduction
in, heavy and prolonged substance use.
Causes clinically significant distress or impairment in
social, occupational, or other important areas of
functioning.
The diagnosis of withdrawal is recognized for the
following groups of substance: alcohol, amphetamines,
and other related substances, cocaine, nicotine, opioids,
and sedatives, and hypnotics.
The signs and symptoms of withdrawal are specific to
substance used.
Substance-Related Disorders
Associated Features
 Diagnosis of substance abuse requires obtaining
a detailed history from the individual as well as
a physical exam.
 Routes of administration that produce more
rapid and efficient absorption into the
bloodstream tend to result in more intense
intoxication.
 The half-life of a substance parallels the aspects
of withdrawal, the longer the duration of action,
the longer the time between cessation and
onset of withdrawal symptoms and the longer
withdrawal is likely to last.
Substance-Related Disorders
Associated Features
 Individuals with Cocaine Dependence frequently use alcohol to
counteract the lingering cocaine induced anxiety.
 Blood and urine tests are used to determine recent use of he
substance.
 Clinicians should use the code that applied to the class of
substances rather than the name for the class, for example
-305.70 Methamphetamine Abuse, instead of Amphetamine
Abuse
 If substance doesn’t fit into any class, use the appropriate code for
other substance, for example
-305.90 Amyl Nitrate Abuse
 If substance is unknown, the code for the class should be used
-292.89 Other or Unknown Substance Intoxication
Alcohol Related Disorders
Alcohol is the most frequently used brain
depressant and the cause of considerable
morbidity and mortality.
 As many as 90% of adults have had some
experience with alcohol, and 60% of
males and 30% of females have had one
or more alcohol related adverse life
event.

Alcohol Use Disorders
Dependence
 Individuals with alcohol dependence often
continue to consume alcohol, despite
adverse consequences, often to avoid or to
relieve the symptoms of withdrawal.
 Only a minority of individuals with alcohol
dependence have experienced clinical levels
of alcohol withdrawals, and only about 5% of
these individuals ever experience severe
complications from withdrawals (i.e. delirium
and seizures).
 Alcohol abuse can only be diagnosed in the
absence of alcohol dependence.
Alcohol Induced Disorders
Intoxication
 In alcohol intoxication one or more of
the following signs develops during or
shortly after alcohol use:
- slurred speech
-
uncoordination
unsteady gait
impairment in attention or memory
stupor or coma.
Alcohol-Related Disorders
Associated Features and Disorders
Associated with significant increase in risk of
accidents, violence and suicide.
1 in 5 intensive care admissions are alcohol
related
At least part of the reported association
between depression and Alcohol Dependence
may be attributable to co morbid depressive
symptoms resulting from the effects of
intoxication or withdrawal.
Alcohol-Related Disorders
Associated Physical Examination Findings and General Medical
Conditions
Repeated intake of high doses of alcohol can affect nearly every
organ system, especially gastrointestinal tract, cardiovascular system,
and central and peripheral nervous system.
Gastrointestinal affects about 15% of heavy alcohol drinkers and
include, liver cirrhosis, gastritis, pancreatitis, and cancer of stomach
and esophagus.
Associated Laboratory Findings
Laboratory indicators of heavy drinking is an elevation of gammaglutamyltransferase (GCT), at least 70% of individuals with high GCT
levels are persistent heavy drinkers.
The level of GCT can be used by clinician to test if the client has
abstained from use.
Alcohol-Related Disorders
Specific Culture, Age and Gender Features
Cultural traditions surrounding the use of alcohol in
family, religious, and social settings can affect alcohol use
patterns and likelihood of alcohol problems to develop.
Asians are less likely to have an alcohol disorder due
to deficiency of the form of aldehyde dehydrogenase
that eliminates low levels of the first breakdown
product of alcohol, in the absence of this enzyme they
get flushed face and have palpitations.
Whites and African Americans have similar rates of
Alcohol Abuse and Dependence, while Latino males
have a higher rate.
Alcohol-Related Disorders
Specific Culture, Age and Gender Features
Low educational level, unemployment, and
lower socioeconomic status are associated
with Alcohol disorders, but it is difficult to tell
cause from effect.
Females tend to have higher blood alcohol
concentrations than males because they tend
to metabolize alcohol more slowly and have a
lower percentage of body water.
Alcohol Abuse and Dependence varies among
age groups, and occurs at a male to female
ratio of 5:1.
Alcohol-Related Disorders
Prevalence and Course
Higher proportions of drinkers are found in urban
and coastal areas.
77% of people use alcohol during the ages of 26
and 34.
Alcohol dependence peaks in the mid 20’s and
30’s.
Dependence has a variable course that is
frequently characterized by remission and relapse.
Higher than 65% have at least 1 year of abstinence
rate following treatment.
Alcohol-Related Disorders
Familial Pattern
 40-60% of the variance of risk is explained
by genetic influence
 Higher risk is associated with greater
number of affected relatives, closer
genetic relationships, and severity of
alcohol related problems in affected
relative.
Caffeine-Related Disorders
Caffeine has a number of different sources
including, coffee, tea, caffeinated soda, over
the counter analgesics and cold remedies,
anti-drowsiness pills, chocolates and cocoa.
U.S. average caffeine intake is 200mg/day
and up to 30% consuming 500mg/day.
Caffeine Related Disorders
Associated Features and Disorders
Mild sensory disturbances have been reported in
higher doses, and these doses can also increase heart
rate.
Heavy use is associated with the exacerbation of
anxiety and somatic symptoms such as cardiac
arrhythmias and gastrointestinal pain and diarrhea.
Caffeine use and sources vary across cultures, the
average caffeine intake in most of the developing world
is less than 50mg/day, while the average daily
consumption in Sweden is more than 400/mg/day.
Caffeine dependence is higher in males than in females.
Caffeine-Related Disorders
Prevalence and Course
The pattern of caffeine intake fluctuates during life
with 80-85% of adults consuming caffeine in any given
year.
Caffeine intake is probably elevated among individuals
who smoke and those who use alcohol.
Caffeine consumption begins in mid teens, increased
consumption through 20’s and into 30’s when use levels
off and perhaps begins to fall.
40% of individuals who have stopped the intake of
caffeine report that they changed their pattern in
response to its side effects and/or health concerns.
Cannabis Related Disorders

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Cannabis includes substances derived from the
cannabis plant and chemically similar synthetic
compounds, most commonly used is marijuana.
Cannabis is usually smoked, but can be taken
orally, usually mixed with tea or food.
Marijuana is the worlds most commonly used
illicit substance.
Cannabis has been used since ancient times for its
psychoactive effects and as a remedy for a wide
range of medical conditions.
It is among the first drugs of experimentation for
all cultural groups.
Cannabis-Related Disorders
Dependence
Individuals may use very
potent cannabis
throughout the day over a
period of months or years
and spend many hours a
day acquiring and using
substance
Individuals persist in use
despite the knowledge of
physical or psychological
problems.
Intoxication
Usually begins with a “high”
feeling followed by
symptoms that include:
Euphoria
Inappropriate laughter
Sedation
Lethargy
Impairment in short-term
memory
Impaired motor
performance
Cannabis-Related Disorders
Associated Features and Disorders
Cannabis may be mixed and smoked with opioids
and hallucinogens
Taken in high doses cannabis has psychoactive
effects that can be similar to hallucinogens
Paranoid ideation ranging from suspiciousness to
frank delusions and hallucinations can occur.
Urine tests for cannabis can be positive within 710 days and heavy use can be positive for 2-4
weeks.
Cannabis smoke contains larger amounts of
known carcinogens than tobacco.
Cannabis-Related Disorders
Prevalence and Course
1996 survey found that 32% of the U.S. have
used cannabis, almost 1 in 11 have used in the
last year, and 5% in the last month.
Dependence and Abuse develop over an
extended period of time, although progression
might be more rapid in young people with
pervasive conduct disorders.
Most people establish a pattern of chronic
use that increases in both frequency and
amount.
Cannabis is often used as a gateway drug.
Cocaine-Related Disorders
Cocaine is a naturally occurring substance
produced by the coca plant and is consumed in
several preparations that differ in potency due to
varying levels of purity and speed of onset.
 Cocaine is usually snorted or taken intravenously.
 Most common form of use in U.S is “crack” a
cocaine alkaloid that is extracted from cocaine by
mixing it with sodium bicarbonate and allowing it
to dry into small “rocks”.
 Crack is easily vaporized and inhaled, and the
effects have extremely rapid onset.

Cocaine-Related Disorders
Dependence
Cocaine has extremely potent euphoric effects and
individuals exposed to it can develop dependence after
using for very short periods of time.
The first sign of dependence is the individual finds it
increasingly difficult to resist using cocaine whenever it
is available.
There is a frequent need for dosing to remain high due
to the short half life of cocaine, which is 30-50 minutes.
Individuals spends a large amount of money on the
drug within a short period of time, which can lead to
theft, prostitution or drug dealing.
Cocaine-Related Disorders
Abuse
 Individual has episodes of
problematic use, neglect of
responsibilities, and
interpersonal conflict, which
often occur around payday or
special occasions, resulting in
a pattern of brief periods of
high doses followed by much
longer periods of occasional
or nonproblematic use.
I
Intoxication
 Usually begins with a “high”
followed by euphoria with
enhanced vigor, hyperactivity,
restlessness, hypervigilance,
interpersonal sensitivity,
anxiety, tension, and alertness.
 The magnitude and direction
of behavioral and physiological
changes depend on many
variables, including the dose
and the individual
characteristics of the person.
Cocaine-Related Disorders
Withdrawal
The symptoms of cocaine withdrawal
include: dysphoric mood, fatigue, insomnia,
increased appetite, intense and unpleasant
feelings, and suicide ideation.
Cocaine-Related Disorders
Associated Features and Disorders
 Cocaine is short acting and produces rapid and
powerful effects in the central nervous system.
 Promiscuous sexual behavior is experienced either as a
result of increased sexual desire or using sex for the
purpose of obtaining cocaine.
 Developed conditioned responses to cocaine related
stimuli is a phenomenon that occurs with most drugs
that cause intense psychological changes and often
contributes to relapse.
Lab Findings
 A single dose can be found in positive in urine test for
1-3 days following use, with high doses results can be
positive for 7-12 days.
 Medical conditions vary based on route of
administration of cocaine.
Cocaine-Related Disorders
Specific Culture, Age, and Gender
 Cocaine affects all races, socioeconomic
statuses, ages, and gender groups in the
U.S.
 Cocaine became an issue in the U.S in the
1970’s with more affluent individuals, it
has shifted to include lower
socioeconomic groups living in both
metropolitan and rural areas.
 Male to female ratio is 2:1.
Cocaine-Related Disorders
Prevalence and Course
 A 1996 survey showed that 10% of the U.S. population
had ever used cocaine, 2% within the last year, and 0.8%
within the last month.
 Highest rates of lifetime use is between ages of 26-34,
highest rate of use over past year is 18-25 year olds.
 There are a two main patterns of self administration:
-Episodic-use tends to be separated by 2 or more
days of nonuse (binges).
-Daily- may involve high or low doses throughout
the day or restricted to only a few hours a day.
 Progression from abuse to dependence occurs over a
few weeks to months.
Amphetamine-Related Disorders
Amphetamine is substances with substituted
phenylethylamine structures, such as
amphetamine, dextroamphetamine, and
metamphetamine(speed), and appetite
suppressants.
 Amphetamines are usually taken orally,
intravenously, or intranasally.
 May be obtained by prescription for obesity,
ADHD, and narcolepsy.
 Most effects are similar to cocaine, but
psychoactive effects last longer.

Amphetamine-Related Disorders
Dependence
 Usage may be chronic, episodic, or occurs in binges.
 Behavior can be aggressive, violent and intense, but
temporary anxiety can resemble a panic disorder.
Withdrawal
 Develops within a few hours to several days after
cessation of heavy and prolonged use
 Weight loss usually occurs during heavy stimulant use,
whereas marked increase in appetite with rapid weight
gain is often observed during withdrawal.
Amphetamine-Related Disorders
Associated Features and Disorders
 Associated with dependence or abuse of other
substances, especially those with sedative properties,
which are usually taken to reduce the jittery unpleasant
feelings.
 Urine tests can remain positive for 1-3 days
 A history of conduct disorder and adult antisocial
personality disorder may be associated with the later
development of an amphetamine related disorder.
 Can be seen throughout all levels of society and more
common among persons between 18-30.
 Male to female ratio 4:1.
Amphetamine-Related Disorders
Prevalence and Course
 Patterns of use differ between locales
 In the 1980’s 25% of adults reported
amphetamine use, in a 1996 survey only
5% of adults acknowledged having used a
“stimulant” and 1% having used within last
year.
 Amphetamines, like cocaine have two
patterns of administration, episodic and
daily.
Hallucinogen-Related Disorder
Hallucinogens are a diverse group of
substances that include LSD, MDMA, and
ecstasy.
 Hallucinogens can be taken orally, smoked,
or injected.
 Exposure to hallucinogens occur first in
adolescence.
 Withdrawal does not occur with
hallucinogens.

Hallucinogen-Related Disorder
Dependence
 Tolerance develops rapidly to the euphoric and
psychedelic effects of hallucinogens.
 The long half life and extended duration of
action of most hallucinogens result in individuals
spending hours to days using and recovering
from their effects.
 Some individuals can manifest dangerous
behavioral reactions due to the lack of insight
and judgment while intoxicated.
 Cravings usually occur after stopping use.
Hallucinogen-Related Disorder
Abuse and Intoxication
 Individuals who misuse hallucinogens are likely to use
them much less that do those with dependence,
however they may repeatedly fail to fulfill major role
obligations at school, work and home.
 Intoxication begins with stimulant effects such as
restlessness and hyperactivity, but with higher doses
more intense symptoms occur, such as:
-Feelings of euphoria may alternate rapidly with
depression and anxiety
-Visual illusions or enhanced sensory experience
-Synesthesias- a blending of senses
-Visual hallucinations of geometric forms and
figures
Hallucinogen-Related Disorder
292.89 Hallucinogen Persisting Perception Disorder
(Flashbacks)
 Essential feature is the transient recurrence of
disturbances in perception that are reminiscent of those
experienced during hallucinogen intoxication.
 The individual has to have had no recent hallucinogen
intoxication and must have no current drug toxicity.
 The abnormal perception associated with this disorder
are self induced or triggered by entering a dark
environment.
 Perceptual disturbances may include geometric forms,
peripheral images, flashes of color, intensified colors,
trailing images, and halos around images.
Hallucinogen-Related Disorder
Associated Features and Disorders
 Environmental factors and personality and
expectations of the individual using
hallucinogens may contribute to the nature and
severity of the hallucinogen intoxication.
 Hallucinogens may be used as part of
established religious practices such as peyote in
the Native American Church.
 Use is 3 times more common in males than in
females.
Hallucinogen-Related Disorder
Prevalence and Course
 The two most commonly used forms of hallucinogens
are LSD and MDMA.
 Peak prevalence was between 1966 and 1970
 A 1996 survey showed that 10% of people 12 and older
acknowledged the use of hallucinogens, the highest
proportion of use is 18-25 years old.
 Intoxication may be a brief and isolated event, but
frequent dosing tends to reduce the intoxicating effects
because of the development of tolerance.
 Depending of the route of administration the peak
effects occur within a few hours to few days after
dosing ends.
DOACLIENTMAP
Charlie Sheen
Description
Charlie Sheen is a 45 year old American film and television
actor. Sheen is the son of actor Martin Sheen, who is a
recovering alcoholic that has been sober for 20 years. Sheen
has been married 3 times and is the father of 5. In 1998 Sheen
overdosed while injecting cocaine, he underwent a year of
rehab. In February 2010, Sheen voluntarily admitted himself to a
rehab facility, only to check himself out in early March of the
same year. Sheen filed for his third divorce in August of 2010,
and in October of 2010 Sheen was arrested after causing
$7,000 worth of damage to a New York hotel room, Sheen
admitted to being under the influence of alcohol and cocaine
during this incident. Since this incident Sheen has been on a
downward spiral having his children removed from his home,
being fired from his job, and making racial slurs that eventually
got him banned from Warner Bros production lot.
Diagnosis
Axis 1: 303.90 Alcohol Dependence
304.20 Cocaine Dependence
Axis 11:
Axis 111: None
Axis 1V: Family and personal history of
substance use and pending divorce
Axis V: GAF = 55
Objectives
The objectives for Mr. Sheen will include, but not be
limited to:
 To enable Mr. Sheen to be admitted to an inpatient and
medically supervised detoxification and rehabilitation
facility for at least 90 days.
 To enable Mr. Sheen to be able to identify triggers for
use and relapse within 12 weeks of treatment.
 To enable Mr. Sheen to identify maladaptive familial
patterns that contribute to his dependence and abuse
within 12 weeks of treatment.
 To enable Mr. Sheen to identify and practice at least four
stress management strategies within 12 weeks of
treatment.
 To enable client to attend Alcoholics Anonymous and
complete at least 1 step within first 6 weeks of
treatment.
Assessment
Will evaluate Mr. Sheen for alcohol and cocaine
dependence through a structured interview
using symptom list from DSM.
 Will evaluate Mr. Sheen for alcohol and cocaine
dependence by administering the SASSI-3(Adult
Substance Abuse Subtle Screening Inventory-3).
 Will evaluate Mr. Sheen for other problems by
interviewing significant others to gather
information that Mr. Sheen may be unaware.

Clinician/Counselor
Mr. Sheen would benefit from a male
counselor that is knowledgeable about
the development and symptoms of
alcohol and cocaine dependence. His
counselor needs to be skilled in setting
goals and able to promote motivation,
independence, and optimism.
Location
Mr. Sheen needs to be admitted to an
inpatient facility that will not only allow
him medical supervision to detox, but
that has a controlled environment that is
conducive for sober living.
Mr. Sheen will also need to be placed in a
facility that will ensure his privacy and
employs staff that will maintain discretion
and confidentiality with matters of public
relations and media.
Interventions
Cognitive behavioral therapy will be used to change the way that Mr.
Sheen thinks in order to change his feeling and actions, even if his
situations do not change.
This therapy will be used to become more aware of inaccurate or
negative thinking and allow him to view challenging situations more
clearly and respond to them in a more effective way.(2)
This therapy will also be used to resolve relationship conflicts and
overcome emotional traumas.(3)
This therapy will be appropriate for learning techniques for coping and
identifying new ways to manage emotions.(4)
Through this therapy Mr. Sheen will learn how to understand how and
why he is doing well, so that he knows what to do to continue to
do well.(2)
Client will attend regular Alcoholics Anonymous meetings which will
provide him with acceptance, understanding, forgiveness,
confrontation, and a means for positive identification.(5)
Emphasis
Counselor will use a directive and supportive
approach to encourage him to respond
positively to counseling. A low level on
confrontation will be used as a part of therapy,
but Mr. Sheen may experience higher levels of
confrontation from his peers in A.A. meetings
and group counseling sessions. A moderate level
of exploration will be used to help the client
understand how his familial patterns and
perhaps genetic factors have played a role in his
dependence.
Number of People
The treatment will consist of individual
counseling between Mr. Sheen and the
clinician, as well a varied amount of
people that will attend his A.A. meetings
and group counseling sessions.
Timing
The client will complete a 90 day inpatient
treatment program. The clinician will meet with
Mr. Sheen three times a week for 45 minute
sessions for the first 6 weeks of treatment and
2 sessions a week for the remaining 6 weeks of
treatment. Mr. Sheen will also attend 1 hour of
A.A. meetings three times a week. Mr. Sheen will
attend 30 minute daily group counseling
sessions facilitated by 2 clinicians for the
entirety of his treatment.
Medication
There are no medications recommended at
this time.
Adjunct
Mr. Sheen can find support groups to help
develop his coping skills and to provide a
network of support.
 Mr. Sheen will need to continue attending
A.A. meetings at lease until he has
completed his 12 steps, and maybe longer
to help prevent relapse.

Prognosis
The length of Mr. Sheen’s abuse and dependence
and the severity indicate that his problem will
be difficult to overcome. Assuming that client
remains abstinent from substances and finds
adequate coping skills to deal with his problems
the client has a good chance of remaining sober.
However, relapse is common.
Due to Mr. Sheen’s celebrity status an assisted
sober living facility may not be an option for
transitioning back into the real world, client
would need to seek assistance in maintaining his
sobriety as well seek out friends that are nonusers.