Substance abuse and Addiction

• Substance Abuse- is when you use legal or illegal substances in ways you shouldn’t. You might
take more than the regular dose of pills or use someone else’s prescription. You may abuse drugs
to feel good, ease stress or avoid reality. But usually, you’re able to change your unhealthy habits
or stop using altogether.
• Addiction- is when you can’t stop. Not when it puts your health in danger. Not when it causes
financial, emotional, and other problems for you or your loved ones. That urge to get and use
drugs can fill up every minute of the day, even if you want to quit.
Freud and Psychoanalysis
• Structure of the Mind
• Defense Mechanisms
• Psychoanalytic Therapy

Neo-Freudian Psychodynamic Perspectives

• Jung and Analytical Psychology
• Adler and Individual Psychology
Behaviorism
• Classical Conditioning
• Operant Conditioning
• Modeling
• Behavior Therapy

Cognition
• Cognitive Therapy
• In cognitive therapy, the therapist typically begins by helping clients become more aware of their
maladaptive thoughts. By changing cognition, therapists hope that people can change their
feelings, behaviors, and symptoms.

Diathesis-stress model
The theory that mental and physical disorders develop from a genetic or biological predisposition for that
illness (diathesis) combined with stressful conditions that play a precipitating or facilitating role. Also
called diathesis–stress hypothesis.
Diathesis-stress model
• The diathesis-stress model of psychopathology is a framework for understanding the development
of psychological disorders.
• According to the general model, each individual possesses some degree of inherent vulnerability
for developing a given disorder.
• Onset of a disorder can then be triggered by environmental stress; however, the amount or
intensity of stress required to trigger a disorder depends on the extent to which the individual is
inherently vulnerable. For example, the greater an individual’s vulnerability to a disorder, the
smaller the amount of stress needed to trigger the development of the disorder.

The Central Nervous System

The Peripheral Nervous System
WHAT IS PSYCHOANALYTIC PSYCHOTHERAPY IN ADDICTION
Psychoanalytic Psychotherapy helps individuals achieve a deeper awareness of
themselves, their unconscious desires, motivations and conflicts. Awareness does
not in itself bring about change, however, it offers the individual a choice; a choice
to not repeat unhelpful and self-damaging patterns.

Parts of the brain that are affected by drug use

The basal ganglia, which play an important role in positive forms of motivation, including the
pleasurable effects of healthy activities like eating, socializing, and sex, and are also involved in
the formation of habits and routines.
These areas form a key node of what is sometimes called the brain’s “reward circuit.” Drugs
over-activate this circuit, producing the euphoria of the drug high. But with repeated exposure,
the circuit adapts to the presence of the drug, diminishing its sensitivity and making it hard to
feel pleasure from anything besides the drug.

The extended amygdala plays a role in stressful feelings like anxiety, irritability, and unease,
which characterize withdrawal after the drug high fades and thus motivates the person to seek the
drug again. This circuit becomes increasingly sensitive with increased drug use. Over time, a
person with substance use disorder uses drugs to get temporary relief from this discomfort rather
than to get high.

How do drugs produce pleasure?

neurotransmitters in parts of the basal ganglia (the reward circuit). When some drugs are taken,
they can cause surges of these neurotransmitters much greater than the smaller bursts naturally
produced in association with healthy rewards like eating, hearing or playing music, creative
pursuits, or social interaction.

It was once thought that surges of the neurotransmitter dopamine produced by drugs directly
caused the euphoria, but scientists now think dopamine has more to do with getting us to repeat
pleasurable activities (reinforcement) than with producing pleasure directly.

Neuroscience Approaches to Treatment

• Antidepressants
• Benzodiazepines
• Antipsychotic drugs
• Stimulants
Substance-Related, Addictive, and Impulse- Control Disorders
• The term substance refers to chemical compounds that are ingested to alter mood or behavior.
• l Psychoactive substances alter mood, behavior, or both.
• l Substance use is the ingestion of psychoactive substances in moderate amounts that does not
significantly interfere with social, educational, or occupational functioning.
• l Substance intoxication us our physiological reaction to ingested substances—drunkenness or
getting high.

Substance-Related, Addictive, and Impulse- Control Disorders

• Substance Abuse
• Drug dependence

Substance-Related, Addictive, and Impulse- Control Disorders

• Another view of substance dependence uses the “drug-seeking behaviors” themselves as a
measure of dependence. The repeated use of a drug, a desperate need to ingest more of the
substance (stealing money to buy drugs, standing outside in the cold to smoke), and the likelihood
that users will resume after a period of abstinence are behaviors that define the extent of drug
dependence.

Six General Categories

• Depressants
• Stimulants
• Opiates
• Hallucinogens
• Other Drugs of Abuse
• Gambling Disorder

Depressants
• Depressants primarily decrease central nervous system activity. Their principal effect is to reduce
our levels of physiological arousal and help us relax.
• Included in this group are alcohol and the sedative, hypnotic, and anxiolytic drugs, such as those
prescribed for insomnia.
• These substances are among those most likely to produce symptoms of physical dependence,
tolerance, and withdrawal.

Alcohol-Related Disorders
 • Apparent stimulation is the initial effect of alcohol, although it is a depressant. We generally
experience a feeling of well-being, our inhibitions are reduced, and we become more out going.
• With continued drinking, however, alcohol depresses more areas of the brain, which impedes the
ability to function properly. Motor coordination is impaired (staggering, slurred speech), reaction
time is slowed, we become confused, our ability to make judgments is reduced, and even vision
and hearing can be negatively affected, all of which help explain why driving while intoxicated is
clearly dangerous.

Sedative-,Hypnotic-,or Anxiolytic-Related Disorders

• The general group of depressants also includes sedative (calming), hypnotic (sleep-inducing),
and anxiolytic (anxiety-reducing) drugs.
• Barbiturates
• Benzodiazepines

Stimulants
• Caffeine
• Nicotine
• Amphetamines
• Cocaine

Caffeine
 Caffeine has a unique mechanism as a stimulant as it works as an inhibitor at the
adenosine receptors. Agonism at these receptors induces a sensation of drowsiness, and
therefore inhibition at these receptors leads to increased energy levels.
 Caffeine also increases intraocular pressure in those affected with glaucoma.
Amphetamines
 The general mechanism of action of amphetamines is the induction of catecholamines,
specifically norepinephrine and dopamine. These catecholamines lead to increased
energy levels, euphoria, increased libido, and higher cognition.
This class also includes non-therapeutic agents such as 3,4-methylenedioxymethamphetamine (MDMA,
aka ecstasy), methylenedioxypyrovalerone (MDPV), and mephedrone.

Methylphenidate
 This drug blocks the dopamine transporter (DAT) and the norepinephrine transporter
(NET), leading to increased dopamine and norepinephrine levels with the inhibition of
their reuptake.
 Ephedrine
 The primary mechanism of ephedrine is increased norepinephrine activity at the
adrenergic receptors. Pseudoephedrine specifically works also as a nasal and sinus
decongestant.
Cocaine
 The induction of most of the effects of cocaine is through the blockade of the dopamine
transporter protein. This results in increased dopamine levels at the synaptic cleft, and
hence the effects of dopamine become amplified.
Pseudoephedrine
 Pseudoephedrine is a drug used as a nasal decongestant and stimulant. It is a
sympathomimetic agent that belongs to the amphetamine and phenethylamine drug
classes. It appears in a number of over-the-counter formulations, including combinations
with guaifenesin, antihistamines, acetaminophen, and dextromethorphan.
Khat (Catha edulis)
 Khat is a flowering plant indigenous to the Arabian Peninsula and the Horn of Africa.
 It contains a substance called cathinone, and the World Health Organization considers it a
potential drug of abuse, although they do not rate it as a serious addiction risk. It is a
keto-amphetamine and is banned in the USA.
Modafinil
 This is a CNS-stimulating agent used to treat sleepiness related to obstructive sleep
apnea, narcolepsy, and shift-worker disorder. It is a weak dopamine uptake inhibitor,
although the precise mechanism for its stimulating effects remains unknown.
Additional stimulants are available, especially in pre-workout supplements, which have direct
agonistic effects on adrenergic receptors. Examples include synephrine, which is present in many
supplements, and methylsynephrine, which the WADA banned. Other known stimulants, such as
1,3-dimethlamylamine (DMAA), have lesser-known pharmacologic mechanisms.

Types of stimulants

Illicit stimulants (street drugs)

 Cocaine or coke
 Ecstasy
 Methamphetamines (an amphetamine that is usually smoked)
 Illegally sold or manufactured amphetamines
 Over-the-counter and prescription stimulants

 Adderall
 Ritalin
 Concerta
 Dexedrine
 Dextroamphetamine (used to treat narcolepsy and ADHD)

Stimulant abuse and addiction

Stimulants are abused in several ways, depending on the type. Stimulant drugs can be
swallowed in pill form, snorted as a powder, injected with a needle or syringe, or heated into
crystal form and smoked. Injected or smoked stimulants reach the brain faster and therefore
produce the most intense highs. Snorting or swallowing stimulants produces a high that is less
intense but longer lasting.

Often, chronic stimulant abusers will try to compensate for diminishing highs by taking more
and more stimulants to experience the same initial pleasure. This can result in increased
dependence and addiction. Stimulants can be fatal, especially when taken in large doses or when
mixed with other substances.

How stimulants affect users

Desired effects of stimulants

 Enhanced alertness
 Wakefulness and endurance
 Increased productivity, motivation and arousal
Short-term side effects of stimulants
 Increased heart rate, blood pressure, and body temperature
 Other cardiovascular irregularities that may include heart attack or complete heart failure
 Hyperactivity
 Weight loss
 Cravings
 Nausea
 Muscle spasms
Overdosing on stimulants can lead to heart problems, strokes, convulsions, and, if not treated
immediately, death.

Long-term effects of stimulant drug abuse

 Addiction
 Severe dental problems
 Delusions
 Visual and auditory hallucinations
 Anorexia
 Problems thinking
 Aggression
 Paranoia
 Psychosis

Factor model & MSE

 • 4P factor model formulation is a tool used in psychology, psychiatry, psychological medicine or
whenever it is deemed necessary and useful. It is quick, easy-to-use, and is a structured method to
describe, assess and observe your patient’s narrative into a coherent and concise record.
• The columns contain the biological, psychological and social risk factors all under as the
biopsychosocial approach. The rows contain the predisposing, precipitating, perpetuating and
protective factors which are under the 4P factor model.

What are the risk factors?

• Risk factors are positively associated to increase the likelihood of the development and
progression of a specific mental health disorder but are not sufficient to cause the disease. These
can be through particular events or characteristics.
• Biological
• Biological generally talks about what the patient has already or was born with such as the
unmodifiable factors. This involves their physical development, their genetics or how prone they
are to develop any diseases or comorbidities and so on. For example, it is proven that an
underweight newborn baby has an increased cardiovascular risk.

What are the risk factors?

• Psychological
• This section focuses more on the person and their mind. How is the person doing mentally or
psychologically? The psychological aspect describes how you perceive yourself, your confidence,
stress, self-esteem, and so on.
 • Personality
• Emotional development
• Coping-strategies
• Self-esteem
• Insight
• Defense
• How to respond to stressors
• Patterns of behavior and cognition

• Social
• Finally, social is about their connectedness with the community and the world. This includes
family and friends, where they live, support from people/friends and human interactions. How
does a person fit in society with their culture or religion? Do they feel they belong and contribute
to society?
• Family and peer relationships
• School
• Neighborhoods
• Culture
• Religion
• Socioeconomic status

What are the components of the 4P Factor Model?

• Predisposing: Why me?
• This can include medical and psychiatric history, family history, temperament genetics and
chronic social stressors. The predisposing risk factors increase the likelihood of a patient to
develop a certain mental health disorder but do not guarantee it.
• Example: family history of physical illness, mental disorder (such as schizophrenia), genetics.

What are the components of the 4P Factor Model?

• Precipitating: Why now?
• What has made them take the decision to come? Something must have triggered the patient to
decide that it was time to make an appointment and see the clinician.
 • Example: bullying, catastrophic events (bushfires, flooding, pandemics), increase level of stress.

What are the components of the 4P Factor Model?

• Perpetuating: Why does it continue?
• These are the current things that are making the patient’s condition endure as symptoms may
progressively become worst. These could be the severity of their condition, compliance issues,
unresolved predisposing and perpetuating factors.
• Example: abusive relationship, substance abuse, unsupportive environment, continuing physical
or mental illness, unresolved precipitating such as ongoing bullying.

What are the components of the 4P Factor Model?

• Protective: What can I rely on?
• The protective factors can reduce and prevent the occurrence and reoccurrence of a mental health
disorder. The protective factors can be the patient’s strength, resilience and support in their lives
or the amount of support they have with their family and social groups.
• Example: not using substances that would cause a reoccurrence of a mental health disorder,
resilience, self-esteem, firm support, education/intelligence, healthy habits, financial stability.
Mental State Examination
• The mental state examination (MSE) is a structured way of observing and describing a patient’s
current state of mind, under the domains of appearance, attitude, behavior, mood, affect, speech,
thought process, thought content, perception, cognition, insight, and judgment.
• The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient’s
mental state, which when combined with the biographical and historical information of the
psychiatric history, allows the clinician to make an accurate diagnosis and formulation.
Appearance
• Distinguishing features: these may include scars (e.g. self-harm), tattoos and signs of
intravenous drug use.
• Weight: note if they appear significantly underweight or overweight.
• Stigmata of disease: note any stigmata of disease (e.g. jaundice).
• Personal hygiene: this can provide insight into the patient’s current ability to care for
themselves.
• Clothing: note if this is appropriate for the weather/circumstances and if the clothes have been
put on correctly.
• Objects: look around to see if the patient has brought any objects with them and note what they
are.

Behavior
• Engagement and rapport
• Eye contact
• Facial expression
• Body language
• Psychomotor activity
• Abnormal movements or postures

Speech
• Rate of speech
• Quantity of speech
• Tone of speech
• Volume of speech
 • Fluency and rhythm of speech

Mood and affect

• Mood
• A patient’s mood can be explored by asking questions such as:
• “How are you feeling?”
• “What is your current mood?”
• “Have you been feeling low/depressed/anxious lately?”

Affect
Range and mobility of affect refer to the variability observed in the patient’s affect during the
assessment. Fixed affect: the patient’s affect remains the same throughout the interview, regardless of the
topic.
Restricted affect: the patient’s affect changes slightly throughout the interview, but doesn’t demonstrate
the normal range of emotional expression that would be expected.
Labile affect: characterized by exaggerated changes in emotion which may or may not relate to external
triggers. they have no control over their emotions.

Thought
• Thought form
• Speed of thoughts
• Flow and coherence of thoughts
• Thought content
• Thought possession

Perception
• Abnormalities of perception include:
• Hallucinations: a sensory perception without any external stimulation of the relevant sense that
the patient believes is real (e.g. the patient hears voices but no sound is present).
• Pseudo-hallucinations: the same as a hallucination but the patient is aware that it is not real.
• Illusions: the misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).
 • Depersonalization: the patient feels that they are no longer their ‘true’ self and are someone
different or strange.
• Derealization: a sense that the world around them is not a true reality.

Cognition
• Cognition refers to “the mental action or process of acquiring knowledge and understanding
through thought, experience, and the senses”. Cognition can be impaired as a result of mental
health conditions and their treatments.
• Throughout the process of performing a mental state examination, you will develop a vague idea
of the patient’s cognitive performance including:
• whether they are orientated in time, place and person
• what their attention span and concentration levels are like
• what their short-term memory is like
Insight and judgment
• Insight
• Insight, in a mental state examination context, refers to the ability of a patient to understand that
they have a mental health problem and that what they’re experiencing is abnormal. Several
mental health conditions can result in patients losing insight into their problem.
• Judgement
• Judgement refers to the ability to make considered decisions or come to a sensible conclusion
when presented with information. Judgment can become impaired in several mental health
conditions leading to poor decision making.

Closing the consultation

• Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.