07 - 2. Psychoactive substance use disorders

2. Psychoactive substance use disorders

© SPMM Course 2. Psychoactive substance use disorders

Mental and behavioural disorders due to psychoactive substance use are dealt in Chapters F10 to F19 in ICD-10. Substances discussed here include alcohol, opioids, cannabinoids, sedatives, cocaine, other stimulants including caffeine, hallucinogens, tobacco, solvents and the use of multiple substances. Various clinical syndromes associated with the use of substances are described:

Syndromes Subdivisions Acute intoxication Transient disturbances in the level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses. Usually related to dose/levels of consumed substance Symptoms need not always in accord with the expected physiological properties of the drug (e.g. a depressant can cause agitation). Harmful use A pattern of substance use that is causing damage to physical or mental health. Should not be diagnosed if dependence syndrome or substance-induced psychosis are diagnosed. Dependence Cognitive and behavioural phenomena indicating that the use of The substance takes on a much higher priority for a given individual than other previously salient behaviours. A checklist of features is described to diagnose each dependence syndrome (also see Edward & Gross criteria given below). Withdrawal state The syndrome occurs on absolute or relative withdrawal of a substance after repeated and prolonged use. Withdrawal Delirium Withdrawal accompanied by confusional state Psychotic disorder Psychotic phenomena that occur during or immediately after psychoactive substance use (esp. auditory hallucinations and paranoid delusions) Amnesic syndrome Chronic impairment of recent memory with relatively preserved remote memory and immediate recall. Late-onset disorders Changes in cognition, emotion and personality or behaviour that persist beyond the period of expected physiological effects of the consumed substance.

ICD10  has  a  diagnostic  code  for  ‘harmful  use’ where the actual damage is caused to the drinker physically or mentally, but he has no dependence pattern (yet). In contrast, DSM-IV upholds the concept  of  ‘abuse’ which refers to maladaptive use

1. Despite problems in social, occupational, physical and psychological domains
2. In hazardous situations
3. At least one month, recurring over a longer period usually.
4. But not dependent on alcohol.

©"SPMM"Course" 8" ! ICD10"alcohol"dependence"requires"at"least"3"out"of"following"list"satisfied"in"last"12"months:"

1. Intense"desire"to"drink"alcohol"
2. Difficulty"in"controlling"the"onset,"termination"and"the"level"of"drinking"
3. Experiencing"withdrawal"symptoms"if"alcohol"is"not"taken"
4. Use"of"alcohol"to"relieve"from"withdrawal"symptoms"
5. Tolerance"as"evidenced"by"the"need"to"escalate"dose"over"time"to"achieve"same"effect"
6. Salience"–"neglecting"alternate"forms"of"leisure"or"pleasure"in"life"
7. The"narrowing"personal"repertoire"of"alcohol"use." ! DSMDIV"alcohol"dependence"requires"at"least"3"out"of"following"list"lasting"for"at"least"a"month:"
8. Consuming"alcohol"for"longer"period"and"in"larger"amounts"than"intended"
9. Unsuccessful"attempts"to"cut"down"
10. Experiencing"withdrawal"symptoms"if"alcohol"is"not"taken"
11. use"of"alcohol"to"relieve"from"withdrawal"symptoms"
12. Tolerance"as"evidenced"by"the"need"to"escalate"dose"over"time"to"achieve"same"effect" (at"least"50%"increase"from"start)"
13. Salience"–"most"time"of"life"spent"on"pursuing"alcohol"directly"or"indirectly"
14. Failure"in"role"obligations"and"physical"health"
15. Giving"up"alternate"pleasures"
16. Continued"use"despite"knowing"the"harm"caused" " ! " " " " " " " " " Edwards"&"Gross"criteria"(1976)"for"dependencem • Narrowed"repertoirem • Salience"of"alcohol"seeking"behaviour

• Increased"tolerance

• Repeated"withdrawals

• Drinking"to"prevent"or"relieve"withdrawals.

• Subjective"awareness"of"compulsion

• Reinstatement"after"abstinence