Demystifying Disorders: Diagnosing Substance Use Disorders

Embark on an enlightening journey with us, Dr. Linton Hutchinson and Stacy Frost, as we cast a spotlight on the perplexing realm of addictive disorders. With our combined expertise, we dissect the layers of dependency, from the initial lure to the grip of withdrawal. Our latest episode is a treasure trove of insights for therapists and curious minds alike, delving into the DSM-5TR's ten classes of potentially addictive substances and behaviors—each with its unique seduction and challenges. We promise that by the end of our discussion, you'll be armed with a nuanced grasp of terms like tolerance and intoxication and a newfound appreciation for the complexity of behavior-based addictions, including the compulsive dance with the highs and lows of crypto trading.

Navigating the stormy seas of addiction requires a compass, and we offer just that by unpacking the critical diagnostic criteria for substance use disorders. Our conversation traverses the intricate landscape of symptoms and specifiers, from impaired control to social impairment, risky use, and the pharmacological nuances that therapists must recognize. We also demystify the concept of remission status and underscore the life-changing impact of maintenance therapy. So, whether you're sipping on your second cup of coffee or seeking enlightenment on the frontline of addiction therapy, tune in for an episode that doesn't just inform—it transforms.

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Transcript

Addictive Disorders

Speaker 1 0:05

Hello to all our wonderful therapists out there. I'm Dr Linton Hunjison and this is my co-host, Stacey Frost.

Speaker 2 0:12

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.

Speaker 1 0:43

People always get those confused, don't they, Stacey?

Speaker 2 0:46

Yes.

Speaker 1 0:47

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.

Speaker 2 1:11

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.

Speaker 1 1:24

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.

Speaker 2 1:43

Yes, and those gummies too, Linton.

Speaker 1 1:45

Oh yeah, that's right.

Speaker 2 1:46

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.

Speaker 1 2:03

Number five inhalants, which are chemicals that produce gases that are breathed by a person, producing psychoactive effects.

Speaker 2 2:14

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.

Speaker 1 2:28

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.

Speaker 2 2:42

Number eight stimulants, which are drugs that increase alertness, focus and energy.

Speaker 1 2:48

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.

Speaker 2 3:14

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?

Speaker 1 3:48

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.

Speaker 2 4:22

Uh-huh.

Speaker 1 4:24

Moving right along. So what substances can be diagnosed as a substance use disorder?

Speaker 2 4:32

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.

Speaker 1 4:44

Caffeine doesn't qualify there Stacy.

Speaker 2 4:47

Uh-uh.

Speaker 1 4:48

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?

Speaker 2 4:59

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.

Speaker 1 5:16

Looks like you lucked out this time Stace.

Speaker 2 5:19

You're telling me, Although I have Linton cut back significantly on my coffee intake these days, maybe two to three cups a day.

Speaker 1 5:28

Is that true? Did you really do that?

Speaker 2 5:31

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.

Speaker 1 5:41

Imagine.

Speaker 2 5:42

So two cups three if it's a really I'm really sleepy.

Speaker 1 5:46

Okay, so why doesn't caffeine qualify as a use disorder?

Speaker 2 5:50

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.

Speaker 2 6:38

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.

Speaker 1 7:37

What do you mean?

Speaker 2 7:39

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.

Speaker 1 7:51

So I see. So I'm not funny anymore. Is that's what you're saying?

Speaker 2 7:55

It's a different kind of funny, more sophisticated.

Speaker 1 8:01

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.

Speaker 2 8:25

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?

Speaker 1 8:39

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.

Symptoms and Specifiers of Substance Use

Speaker 2 9:05

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. A substance use disorder diagnosis is based on evidence of impaired control, social impairment, risky use and pharmacological criteria like tolerance and withdrawal.

Speaker 1 9:38

Okay, so exactly what kind of symptoms are you talking about?

Speaker 2 9:42

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.

Speaker 1 10:28

So you spending all that time in publics looking at the coffee aisles? Is that part of it?

Speaker 2 10:34

Oh yes, yes, spending long hours gazing at the coffee aisle trying to narrow down which one to try this week.

Speaker 1 10:42

But then again, it's not a substance use disorder, right.

Speaker 2 10:46

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.

Speaker 1 11:19

Ah, I got it Stacey. And the next group of symptoms are all related to social impairment, right?

Speaker 2 11:25

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.

Speaker 2 12:05

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?

Speaker 1 12:59

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.

Speaker 2 13:56

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?

Speaker 1 14:25

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.

Speaker 2 15:18

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.

Speaker 1 15:41

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.

Speaker 2 15:52

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.

Speaker 1 16:06

Yes, you may.

Speaker 2 16:07

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.

Speaker 1 16:29

Something tells me there's more to this specifiers story.

Speaker 2 16:34

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.

Speaker 1 17:32

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.

Speaker 2 17:47

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.

Speaker 2 18:24

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.

Speaker 1 19:09

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.

Speaker 2 19:44

Right, exactly.

Speaker 1 19:46

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.

Speaker 2 20:16

Good so far. Any other specifiers you want to tack on?

Speaker 1 20:20

OK, he said that he's been sober for four months, so I guess we could tick off that box for an early remission.

Speaker 2 20:32

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?

Speaker 1 20:38

huh, yes, you did, congratulations.

Speaker 2 20:40

Congratulations, you're getting very good at specifiers.

Speaker 1 20:43

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.

Speaker 2 21:06

Caffeine coffee.

Speaker 1 21:07

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?

Speaker 2 21:35

A 12 month period of time.

Speaker 1 21:38

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?

Speaker 2 22:01

Two to three.

Speaker 1 22:03

Moderate.

Speaker 2 22:04

Four to five.

Speaker 1 22:05

And severe.

Speaker 2 22:07

Six or more.

Speaker 1 22:09

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. Other specifiers include remission status, being on maintenance therapy and being in control of their environment.

Speaker 2 22:27

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.

Speaker 1 23:12

And until next time, only consuming two to three cups of coffee a day. Coffee a day hits in this.