Substance-Related Disorders

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Some say that the complexity of the problem of illicit substance use is reflected in the complexity of the terminology used to define it. The old term “addiction” has given way to four disorders that describe different stages of involvement with the illicit substance. As defined by the Diagnostic and Statistical Manual of Mental Disorders 4th ed. (American Psychiatric Association [APA], 2000), substance intoxication refers to “the development of a substance-specific syndrome due to recent ingestion of (or exposure to) a substance.

” While both substance abuse and substance dependence are each described as “a maladaptive pattern of substance use leading to clinically significant impairment or distress,” there are several criteria that point to the latter but not the former, such as tolerance and spending a great deal of time in activities necessary to obtain the substance. Finally, substance withdrawal is defined as “the development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged.

” Different psychological paradigms offer different theories as to the etiology of substance-related disorders (Sadock & Sadock, 2003). The classic psychodynamic school of thought sees substance abuse as a masturbatory equivalent, a defense against anxious impulses, or a manifestation of oral regression. The more modern psychodynamic approach associated substance use with depression and disturbed ego functions. Psychosocial theories attribute substance use to unhealthy relationships with the family and with society in general.

Behavioral theories refer to the positively reinforcing attributes of many of the substances of abuse, and they relate substance-seeking behavior with certain cues. Supporters of a genetic etiology have found a strong genetic component through studies of alcohol abuse in twins, siblings and adoptees reared apart. Finally, neurochemical factors have been identified that are involved with most substances of abuse; for example, people with too little endogenous opioid activity are at risk for developing opioid dependence.

One substance that is not often associated with “addiction,” but is nevertheless the most widely consumed psychoactive substance in the world (Sadock & Sadock, 2003) is caffeine. It is estimated that an adult in the United States consumes an average of 200 mg of caffeine daily, with 20-30% of all American adults consuming more than 500 mg caffeine daily. The usual factors that contribute to “addiction” do not all apply to caffeine.

Unlike those who abuse substances such as amphetamines or narcotics, people who overindulge in caffeine do not necessarily come from troubled homes or have disturbed ego functions. However, genetics surprisingly also have a role in caffeine use (Sadock & Sadock, 2003). Scientists have found that there may be a genetic predisposition to continued coffee use following initial exposure to it. As a substance of abuse, caffeine shares similar characteristics to the other substances that cause disorders.

For example, caffeine is a positive reinforcer, especially at low doses, since 100 mg can induce a mild euphoria, increased alertness, a mild sense of well-being, and a sense of improved verbal and motor performance (Sadock & Sadock, 2003). Another similarity is that physical tolerance was found to develop in both animals and humans to some of the effects of caffeine, and the subjects also experienced withdrawal symptoms. Treatment of caffeine-related disorders consists of managing the symptoms and weaning the patient off caffeine.

The headaches and muscle aches characteristic of caffeine withdrawal can usually be managed by analgesics or, at most, small dosages of benzodiazepines for 7 to 10 days. Reducing or eliminating caffeine use is first managed by having the patient document his or her daily consumption of caffeine and determining the average amount of caffeine consumed daily. The patient and his clinician then agree on a fading schedule of caffeine consumption. Dependent Personality Disorder

Dependent personality disorder, known to some as passive-dependent personality, is a condition where a person subordinates his or her needs to the needs of others, gets other people to assume responsibility for various aspects of his or her life, is lacking in self-confidence, and is often uncomfortable when left alone for more than a brief period of time. Prevalence An estimated 2. 5% of all personality disorders are reported to fall into this category, according to Sadock & Sadock (2003). It is said to be more common in women than in men, and in younger children than in older ones.

In addition, those people who, as children, suffered from chronic physical ailments are more prone to dependent personality disorder. Symptoms A person who has dependent personality disorder is “characterized by a pervasive pattern of dependent and submissive behavior” (Sadock & Sadock, 2003). They often ask for excessive advice from others and seek reassurance repeatedly before making decisions. When it comes to organizations, people with a dependent personality tend to avoid roles that entail significant responsibilities and would rather be a submissive member than assume a leadership position.

Since they often cannot act independently, without close supervision, they tend to be impaired in occupational functioning. Dependent personalities tend to willingly suffer abuse. They would rather put up with a partner who is alcoholic, unfaithful or abusive rather than break their sense of connection. Other characteristics that typify those with this disorder are passivity, pessimism, self-doubt, and fear of expressing feelings of aggression or attraction. Interestingly, someone with dependent personality disorder can become half of a psychological phenomenon called folie a deux, or shared psychotic disorder.

His or her partner becomes the aggressive, assertive partner on whom he or she depends. Although this is an extreme example, this illustrates the way people with dependent personality disorder seek out dependable people because they dislike being alone. Their need for attachment to other people distorts their relationships, and these relationships are often limited only to those with people on whom they can depend. When they lose those persons, to death or otherwise, dependent personalities run the risk of developing major depressive disorder.

Diagnosis The Diagnostic and Statistical Manual of Mental Disorders 4th ed. (American Psychiatric Association [APA], 2000) sets the following criteria for diagnosis of dependent personality disorder: “A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. has difficulty making everyday decisions without an excessive amount of advice and reassurance from others 2. needs others to assume responsibility for most major areas of his or her life 3. has difficulty expressing disagreement with others because of fear of loss of support or approval.

Note: Do not include realistic fears of retribution 4. has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy) 5. goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant 6.

feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself 7. urgently seeks another relationship as a source of care and support when a close relationship ends 8. is unrealistically preoccupied with fears of being left to take care of himself or herself Treatment With the proper treatment, the prognosis for dependent personality disorder is favorable (Sadock & Sadock, 2003). Psychotherapy. Patients with dependent personality disorder often undergo insight-oriented therapy, which helps them understand the origins of their behavior.

Other types of therapy that are used for this disorder include family therapy, group therapy, assertiveness training, and behavioral therapy. With the help of a therapist, and with the support of their family and other members of their social circle, dependent people gradually – and often successfully – learn to be assertive, independent and self-reliant. Pharmacotherapy. There are no medications prescribed for the personality disorder itself, but patients often have symptoms that necessitate the use of drugs.

Usually, panic attacks and separation anxiety are reduced by medications such as imipramine, benzodiazepines or serotonergic agents. Psychostimulants may also be used when the patient’s withdrawal symptoms or depression are found to be responsive (Sadock & Sadock, 2003). * I chose to write about dependent personality disorder because of the possibility of abuse. These people are so attached to their partners or to other significant people in their lives that they tend to stick to the relationship even when it has become physically or emotionally abusive.

This is something that everyone concerned – family members, marriage counselors, law enforcement personnel, among others – should watch out for.

References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed. Text rev. ) Washington, DC: American Psychiatric Association Sadock, B. J. , & Sadock, V. A. (2003). Synopsis of Psychiatry: Behavioral Sciences / Clinical Psychiatry (9th ed. ). Philadelphia, PA: Lippincott Williams & Wilkins.

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