¶ Addictive Disorders
Hello to all our wonderful therapists out there . I'm Dr Linton Hunjison and this is my co-host , Stacey Frost .
Hi everyone . I want to give a special shout out to Abigail in Michigan , who just signed up to start studying for her exam . Good luck to you , abigail . Today in our demystifying disorders series , we're going to give you a primer for the addictive disorders .
In the DSM-5TR , we'll be reviewing the different classes of substances , drugs that have addiction potential , the diagnostic criteria for substance use disorders and some of the terms associated with addiction , like tolerance , withdrawal and intoxication .
People always get those confused , don't they , Stacey ?
Yes .
Okay , let's start by introducing the 10 families of substances and addictive disorders . One alcohol . This is classified as a central nervous system depressant that slows down brain functioning , though at lower dosage it can also act like a stimulant , giving the person a sense of euphoria and lowered inhibitions .
All right . Number two is caffeine , which is considered a central nervous stimulant , found in a variety of forms including coffee , tea , soda , energy drinks , pills and certain types of over-the-counter medications .
Three cannabis or marijuana , which is usually thought of as a depressant with stimulant and hallucinogenic qualities . Cannabis is most commonly smoked , but can also be ingested by mixing it into food , such as brownies .
Yes , and those gummies too , Linton .
Oh yeah , that's right .
Yeah , and number four , hallucinogen related , which is split into the classic hallucinogens like LSD and the dissociative drugs like Fensicladine , aka PCP . Hallucinogens alter perception , mood and cognition .
Number five inhalants , which are chemicals that produce gases that are breathed by a person , producing psychoactive effects .
Number six is opioids , which are primarily used for pain relief , but can be highly addictive . They activate the brain's reward and pleasure centers by flooding the brain with dopamine , creating euphoric effects and reinforcement to keep using them .
Number seven sedatives and hypnotics , which are considered central nervous system depressions . In lower dosages they can help with anxiety , while in higher dosages they can help with insomnia .
Number eight stimulants , which are drugs that increase alertness , focus and energy .
Number nine tobacco , which is highly addictive , containing nicotine in the connectives , both as stimulant and as depressing . Research shows nicotine can be as addictive as heroin , cocaine and alcohol . In some respects , nicotine stimulates strong neural associations that make people want to continue using it despite all negative consequences .
And number ten gambling , which is when someone places a bet , using money or something valuable , on an event that has an uncertain outcome , hoping to get back something of greater value . Now , this is considered an addictive behavior because it stimulates the brain's reward system , just like alcohol or other drugs .
So , linton , speaking of gambling , if you knew someone who was into cryptos and is checking a crypto price ticker continuously during the day , would that behavior fit into the gambling category ?
That's a really good question , Stacy . Anyway , what asset do you know that can increase the value from $800 to $45,000 in less than 10 years ?
But overall , if crypto trading is causing obsessive behaviors , emotional issues , problems in life functioning or an inability to stop despite harmful consequences , it likely constitutes a full-bone addiction that may require professional intervention .
Uh-huh .
Moving right along . So what substances can be diagnosed as a substance use disorder ?
So all substances except for caffeine can be diagnosed as use disorders , for example alcohol use disorder , opioid use disorder , gambling use disorder , et cetera .
Caffeine doesn't qualify there Stacy .
Uh-uh .
So if you knew someone who had to consume , let's say , six cups of coffee to make it through the day , isn't that considered a caffeine use disorder ?
Nope , Caffeine does not qualify as a use disorder , at least right now . So caffeine use disorder is listed as a condition for further study in the DSM-5TR , but currently you can only be diagnosed with caffeine intoxication or caffeine withdrawal .
Looks like you lucked out this time Stace .
You're telling me , Although I have Linton cut back significantly on my coffee intake these days , maybe two to three cups a day .
Is that true ? Did you really do that ?
Yeah , I did . There was a time , especially in college , where I was drinking way too much caffeine and it was causing some physical problems and stuff . So yeah , I really had to cut back .
Imagine .
So two cups three if it's a really I'm really sleepy .
Okay , so why doesn't caffeine qualify as a use disorder ?
Okay , so there are a few reasons that I'll tell you about , just in case you encounter a client who's hopped up on caffeine on your exam . There's no major health effects . The amount of caffeine that's found in food and drinks is not associated with severe long-term health effects or increased mortality risk , even at high intake .
This is kind of in contrast to some of the other things that are addictive , like alcohol , opioids those cause major health effects , liver damage , stuff like that .
Control and judgment are not significantly altered , so while it is stimulating , caffeine doesn't produce psychoactive , euphoric or intoxicating effects that are characteristic of drugs that lead to abuse and impaired control .
There's a little risk of dependence , though caffeine withdrawal symptoms like headaches and fatigue can occur when someone who's used to consuming caffeine stops abruptly , the dependence risk is considered mild compared to substances that flood neurotransmitter pathways .
The severity of withdrawal symptoms tends to be relatively low as well in most cases , and there's a less risk of tolerance . So most caffeine drinkers tend to stabilize their intake around a daily level rather than continually increasing quantity consumed to a perilously high amount . That's indicative of addictive disorders .
They can experience caffeine intoxication if they do consume high doses of caffeine , though , and the last reason is that use typically decreases naturally later in life . As opposed to other substances , many people end up really reducing their caffeine consumption for sleep and anxiety reasons as they age , like some people I know .
What do you mean ?
Oh well , linton , let me remind you . Do you remember the days of Linton on caffeine ? I have never laughed so much in my life . But now I'm adjusting to Linton on celery juice .
So I see . So I'm not funny anymore . Is that's what you're saying ?
It's a different kind of funny , more sophisticated .
Hey , now , now I've been accused of a lot of things , but let's not get too crazy , stacy Also , I don't know about that little risk of dependence , stacy , but maybe when the next edition of the DSM comes out we might see a new diagnosis of caffeine use disorder there .
Yes , along with internet gaming disorder , what Well , believe it or not , that's another condition for future study . I think we need to get Wes to look into that one , with all those hours that he spends on call to duty . What do you think ?
No kidding . Well , before we go far down that black hole , let's get back to the disorders that are currently diagnosable in the substance and addiction disorders category . So we know that there are at least 10 substances and addictive behaviors that we mentioned before , except for caffeine , that can be diagnosed as a use disorders .
Tell us a little more about those Stacy .
Sure . To meet criteria for a use disorder , your client has to have at least two out of 11 symptoms that they've experienced over the course of 12 months . So this means that , as a therapist , you're going to gather a detailed history of the client's substance use in the past year to determine if there's a chronic problematic pattern of substance use .
¶ Symptoms and Specifiers of Substance Use
A substance use disorder diagnosis is based on evidence of impaired control , social impairment , risky use and pharmacological criteria like tolerance and withdrawal .
Okay , so exactly what kind of symptoms are you talking about ?
Okay . So the first group of symptoms relate to impaired control . Number one the client may use the substance in larger quantities and for longer than intended . For example , the client plans to have one drink but actually ends up having four . Number two the client may try to reduce their use or quit using the substance altogether , but they can't .
So let's say , the client tries a detox challenge but they can't stick with it . Or they make a rule to only use on weekends , but they keep breaking their own rule .
Number three the client may spend a lot of time trying to obtain the substance , and here's a couple of scenarios that meet this criteria the client visits multiple doctors for prescription medications , or maybe they drive long distances to meet dealers .
So you spending all that time in publics looking at the coffee aisles ? Is that part of it ?
Oh yes , yes , spending long hours gazing at the coffee aisle trying to narrow down which one to try this week .
But then again , it's not a substance use disorder , right .
That's true , at least not yet . Okay . And so the fourth group of symptoms that relate to impaired control is the client might encounter strong impulses or cravings to engage in continued use . This is where the client has intrusive thoughts about using , or they feel like they need , the substance .
So that's the impaired control symptoms Using more or for longer than intended , trying to quit but can't spending a lot of time trying to get the substance and experiencing cravings .
Ah , I got it Stacey . And the next group of symptoms are all related to social impairment , right ?
That is correct . So we're going to continue on our list here and pick up at number five the use leads to trouble fulfilling obligations at home , work or school . Substance use may interfere with the client fulfilling essential commitments , resulting in tardiness or absenteeism professionally and a failure to take care of critical household duties .
Preoccupation with consumption can overtake obligations of employment and needed family functions like paying bills on time or dependable child supervision . Number six the use causes social and or interpersonal problems and the person continues to use in spite of this .
For example , the client might get complaints from family members about behavior when they're drinking or using drugs and the substance uses damaging relationships , but the client continues to use . And number seven the use causes the person to give up involvement in social , work-related or recreational activities .
This could be something like the client cancelling a fishing trip with his buddies last month because he didn't want to be away from alcohol for the whole weekend , and he's also stopped going in for his weekly basketball games with friends , which he really used to enjoy participating in .
So to recap , the social impairment symptoms are use leads to trouble-fulfilling obligations , causes problems with friends and family and leads the client to stop participating in social activities . Okay , so the next group of symptoms is all about risky behavior . Linton , can you walk us through these symptoms ?
Sure Eight the use leads to dangerous situations . A classic example of that is when a client is driving under the influence of drugs , putting themselves and others at danger , or they combine prescription medications with alcohol , risking a dangerous interactions .
Number nine the use leads to physical or psychological problems and they continue to use it in spite of this .
A few examples of this is when a client continues to drink heavily even after being diagnosed with liver damage from alcoholism , or a methamphetamine user continues using despite experiencing significant weight loss , dental problems and skin's abscesses associated with meth use .
Yeah , you know that your client is in the land of addiction when they experience significant , often irreversible , damage to their bodies and they're still not able to stop using .
So , summing it up , the risky behavior can manifest as involvement in hazardous or dangerous situations , like Linton said , driving under the influence and or continuing to use despite knowing that the substance is causing really serious physical or psychological problems . All right , how about the last group of symptoms , linton ?
Okay , the last group of symptoms are pharmacological in nature , dealing with tolerance and withdrawal . These are two terms you need to be familiar with if you're preparing for an exam .
All right , the client has built up a tolerance to a substance , which means that they are either A A need for the substance to achieve intoxication or B they experience a significant decrease in the effects when using the same amount of that substance .
The client has developed withdrawal , which means they are either A have met a diagnostic criteria for withdrawal symptoms or B the substance is taken to avoid withdrawal symptoms .
And it's important to note that significant withdrawal has not been documented after continued use of fensiclidine , other hallucinogens and inhalants . So for those three substances withdrawal is not included in the criteria . All right , well , that was a heck of a list , linton .
So remind me how many symptoms the client has to have from that list to qualify for a substance use disorder .
Okay , of all those symptoms , they only need to meet two of those criteria and I'm sure you went to tell us about the different specifiers of substance use disorders .
Next , stacey , I'm sure Well , no discussion about diagnostic criteria for mental disorders would be complete without the specifiers . So , yes , I'm happy to do that and I stand by this being important because you might find specifiers on your exam .
Yes , you may .
Yes , so the severity of the disorder is based on the number of symptoms the client has . So this is some specifiers you might come across , or severity specifiers Mild means the person has two to three symptoms , moderate is indicating they have four to five symptoms and severe is when your client has six or more symptoms .
Something tells me there's more to this specifiers story .
Oh well , my bad , linton . I shouldn't have tried messing you with you by keeping those extra specifiers under wraps . You're just too sophisticated for those shenanigans . Linton , you caught me . The jig is up . The other specifiers you need to know about are in early remission .
Now , this is when none of the criteria have been met for at least three months , except for having cravings . In sustained remission , when none of the criteria have been met for at least 12 months , also with the exception of having cravings . On maintenance therapy , when the client is taking a medication to help with issues like withdrawal and cravings .
For example , methadone is the most well known medication to help clients with opioid addiction , and in a controlled environment . This is where the client might be in a substance free jail or a residential treatment facility .
This is just too much information . Stacey , it really is , yeah no kidding . Give me an example so I know what that would look like strung on together , if I saw it on an exam .
Okay , so the first example I'm going to give you is one for alcohol use disorder , and then we'll kind of talk about the specifiers . After I read it , donovan is a 32 year old sales manager who was referred to treatment by his employer due to concerns about his drinking .
Donovan reported that he typically starts off with the intention to drink one to two beers nightly after work , but he actually ends up drinking around four or five beers . He tells you that this pattern has persisted for the past two years since it divorced . Co-workers noticed him smelling alcohol in his breath at morning meetings .
He's received a DUI arrest six months ago after driving home from a bar . Now , during the course of therapy , donovan was educated on risks of excessive alcohol use and he provided motivational interviewing on behavior changes .
He committed to a 30 day period of alcohol abstinence and weekly therapy sessions addressing stress management and alternative coping skills to drinking . At this time , donovan reports four months of sobriety . He denies alcohol cravings or withdrawal symptoms . He exhibits enhanced mood and work performance , indicating early remission and function .
Continued follow up is going to focus on relapse prevention strategies . So , linton , with that information , what specifiers would apply in Donovan's case , I thought the specifiers were your area of expertise .
So the first thing you would think about is like severity wise , that's what you would think of . How severe is it ? So I would say it's mild because he meets three of the criteria for alcohol use disorder . Alcohol is often taken in larger amounts over a longer period of time .
That was intended , as evidenced by his nightly beer conception , in larger amounts than he wanted to . He said that he wanted to drink one or two beers . Right , but he ends up drinking what ? Five , four to five .
Right , exactly .
So reoccurrent alcohol use resulting in a failure to fulfill major role obligations at work , school or home . And that's evidenced because he has issues at work . Ok , Recurrent alcohol use in situations in which it is physically dangerous , and that was because of why Stacey Remember that DUI charge the . Dui arrest . That's right , all right .
Good so far . Any other specifiers you want to tack on ?
OK , he said that he's been sober for four months , so I guess we could tick off that box for an early remission .
Exactly . All right , bravo . So , linton , how about a recap of what we've talked about in this episode ? Ok , so I got that one right ?
huh , yes , you did , congratulations .
Congratulations , you're getting very good at specifiers .
All right , here's the summary . There are 10 classes of addictive substances alcohol , caffeine , cannabis , hallucinogens , inhalants , opiants , sedatives , stimulants , tobacco and gambling . All except which one , Stacey .
Caffeine coffee .
Yes , can be diagnosed as a substance use disorder if the criteria is met . So on the exam , if they say the individual is drinking excessive amounts of caffeine , they still cannot be diagnosed as a substance use disorder . To diagnose a substance use disorder , the client must exhibit at least two of 11 symptoms . Over how long ?
A 12 month period of time .
Exactly . The symptoms fall into categories related to impaired control , social impairment , risky use , tolerance and withdrawal . All right , the disorder severity is specified as mild , moderate and severe . How many symptoms for mild ?
Two to three .
Moderate .
Four to five .
And severe .
Six or more .
So you would go ahead and check that out in the case study that was presented so you would know how many symptoms they have .
¶ Understanding Addiction Terminology and Specifiers
Other specifiers include remission status , being on maintenance therapy and being in control of their environment .
And key addiction terms that you need to know include tolerance , which is where you need more of the substance over time to get the same effect . Withdrawal , which involves unpleasant physical and psychological symptoms that occur when someone who is physiologically dependent on a substance suddenly reduces or stops using that substance .
Intoxication this is the temporary state that occurs after taking a psychoactive substance , resulting in disturbances in consciousness , cognition , perception , judgment or behavior . And cravings , which are the intense urge or desire to use a specific substance . Cravings are considered one of the hallmark features of substance dependence and addiction .
And until next time , only consuming two to three cups of coffee a day . Coffee a day hits in this .