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Introduction to Psychoactive Substance Use Disorders

A Psychoactive drug is one that is capable of altering the mental functioning. There are four patterns of substance use , which may overlap with each other Pattern of use

Any use of substance without any problem.
  1. Intoxication                       
  2. Harmful use or abuse When it is associated with
  3. Legal, Social, physical & Psychological problems
  4. Dependence – Characterised by​
    1. Tolerance – Increasing amount is used for same pleasure.
    2. Withdrawal
    3. Craving - Strong desire to take the substance
    4. Compulsion - Difficulty in controlling substance taking behavior
    5. Taking despite harm - Persistence with the substance despite overtly harmful consequences
    6. Prioritization - Neglect of alternate pleasurable activities, overwhelming involvement in having/seeking  substance.
N.B. Reverse Tolerance: Reverse tolerance or sensitization is the phenomenon of a reversal of the side-effects from a drug, the reduction of insensitivity caused after drug tolerance has been established, or, in some cases, an increase in specific effects of as single drug existing alongside a tolerance to other effects of the same substance. As in alcoholics, when the patients Liver is damaged , then even with the low doses the patient would experience the same effect with even with small amount of Alcohol.
Etiological factors is substance use disorders
There are several predisposing factors for substance or drug abuse. These factors may be :-
  1. Biological           
  2. Psychological                   
  3. Social.
Biological factors Psychological factors Social factors
  • Genetic vulnerability(family History of substance use disorder, e.g., in type II alcoholism)
  • Co- morbid psychiatric disorder or personality disorder
  • Co-morbid medical disorders reinforcing effects of drugs (explains continuation of drug use)
  • Withdrawal effects and craving (explains continuation of drug use)
  • Biochemical factors (e.g., role of dopamine and norepinephrine in concaine, ethanol and opioid dependence)
  • Curiously; need for novelty seeking
  • General rebelliousness and social
  • Early initiation of alcohol & tobacco
  • Poor impulse control
Sensation-seeking (high)
  • Low self-esteem (anomie)
  • Concerns regarding personal autonomy
  • Poor stress management skills
  • Childhood trauma or loss
  • Relief from fatigue and! or boredom
  • Escape from reality
  • Lack of interest in conventional goals
  • Psychological distress
  • Peer pressure (often
more important than parental factors)
  • Modeling (imitating behaviour of important others)
  • Ease of availability of alcohol and drugs
  • Strictness of drug law enforcement
  • Intrafamilial conflicts
  • Religious reasons
  • Poor social/familial support
  • 'Perceived distance'
  • Permissive social attitudes
  • Rapid urbanization

Motivation cycle: Given by Prochaska and Diclemente
Alcohol - Alcohol is a CNS suppressant.
                Effect of Blood Alcohol Level in the Absence of Tolerance
Blood Level, mg/dl Usual Effect     
Decreased inhibitions, a slight feeling of intoxication
Decrease in complex cognitive functions and Motor performance
Obvious slurred speech, motor incoordination irritability, poor judgment
Light coma and depressed vital signs

Types of alcoholism:
  1. Alfa: excessive intake, no loss of control                                                       
  2. Beta: Physical complications, no dependence
  3. Gamma: physical and psychological dependence, Most severe
  4. Delta: Loss of control, amount can be controlled
  5. Epsilon: Dipsomania, spree drinking
Physical Effects of Chronic Alcoholism
Cardiovascular Cardiomyopathy, Hypertension.
Gastro-intestinal Oro-pharyngeal cancer, Oesophageal cancer, Gastritis, Mallory-Weiss syndrome, Pancreatitis, Malabsorption.
Liver Fatty change, Acute hepatitis, liver cancer.
Neurological Cerebral haemorrhage, Peripheral neuropathy, Dementia Wernicke-Korsakoff syndrome, Cerebellar degeneration.
Musculo-skeletal Myopathy, Gout.
Respiratory Pneumonia, Tuberculosis.
Endocrine &  Reproductive Hypoglycaemia, Hypogonadism, Pseudo-Cushing’s syndrome, Infertility
Foetal alcohol syndrome.
Skin Spider naevi, Palmar erythema, Acne rosacea.

In alcoholic paranoia there are certain features to be differentiated from schizophrenia.

Alcohol induced psychotic disorder or alcoholic hallucinosis Schizophrenia                      
1. Usually commences as illusion. Progressing to elementary hallucination to well formed hallucination 1.  Hallucinations from beginning
2. Can recognize the owner of the voice of the 2.  Doesn’t necessarily recognize the owner voice.
3. Address the patient directly usually derogatory or commanding type                                3.  3rd person auditory hallucination
4. Insight regained as soon as hallucination stop 4. No insight
5. No or minimal
  • Thought disorder
  • Affective in appropriates or blunting   
  • Disorganization  
  • Catatonic feature                   
5.  Present
6. Delusion are secondary and Transient 6. Primary or secondary
7. Usually occurs at a time when patient Consumption is reducing his alcohol intake both may exacerbate the illness 7. Reduction or increased alcohol
8. Rapid response to anti psychotics / 6 month 8.  Slow
9. Remits within max. 6 months of abstinence 9.  Follow own course.

Treatment of alcohol induced psychotic disorder is antipsychotics only , however the dose need is less and for shorter duration of time – 4 to 6weeks only.
CNS Complications due to alcohol:
  1. Wernicke’s encephalopathy
  2. Korsakoff ’s syndrome
  3. Marchiafava-Bignami disease: degeneration of corpus callosum
  4. Dementia
  5. Cerebellar degeneration
  6. Central pontine myelinosis
Korsakoff Syndrome
In psychiatry the most significant disorder is the amnestic syndrome caused by thiamine deficiency. When this has an abrupt onset the patient becomes acutely confused; mental state examination reveals drowsiness, disorientation in time and place and an impaired ability to recall recent events or to register new information.
Physical examination reveals a horizontal nystagmus, evidence of external ocular palsies, ataxia and peripheral neuropathy. This syndrome, known as Wernicke’s encephalopathy, results from damage to the mammillary bodies, dorso-medial nuclei of the thalamus and adjacent areas of grey matter. Wernicke’s encephalopathy is due to poor nutrition associated with chronic alcoholism; other causes are prolonged vomiting, diarrhea and severe starvation.
Pathology – Site – B/L dorsomedial nuclei of thalamus and mammillary body, hypertrophy of astrocytes.

Immediate treatment with thiamine 50 mg I/v is essential to minimize permanent damage.
When recovery is incomplete a chronic amnesic syndrome develops; this being known as Korsakoffs psychosis. Characteristically the patient is fully conscious but has a profound impairment of recent memory recall and new learning ability. A striking feature is a tendency to confabulate which has been defined as a falsification of memory in clear consciousness. For example if the patient is asked to describe his activities during the previous week he will reply by reporting events which have taken place many years previously. Confabulation probably results from an inability to distinguish the temporal sequence of past events.
Amnesia also occurs in bilateral lesions of the hippocampus and hippocampal gyrus which are situated on the inferomedial aspect of the temporal lobe. The conditions chiefly responsible are herpes simplex encephalitis and CVA localized to the posterior cerebral arteries. The clinical picture is similar to that of Korsakoff ’s psychosis except that confabulation does not occur.

Wernicke Vs Korsakoff
  Wernicke Korsakoff
Course Acute Chronic
Reversibility Yes No
Presentation Ataxia, nystagmus, ophthalmoplegia Confusion, psychosis, anterograde and retrograde amnesia
Global confusion Present Absence
Treatment Thiamine Thiamine

Other deficits associated with focal brain lesions include expressive and receptive aphasias, apraxias and agnosias

Intoxication: - Transient condition following excessive use of substance.

Clinically significant maladaptive behavior eg inappropriate sexual or aggressive behavior, mood lability, impaired judgment etc.

Signs :- Slurred speech, Incoordination, Unsteady gait, Nystagmus, Impairment in Attention or memory & Stupor or Coma.

Treatment:- Symptomatic and supportive

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