SUBSTANCE DISORDER

Alit Aryani
Psychiatric Departement
Medicine Faculty Udayana University
 Introduction
Substance abuse problem cause significant
disabilities
Illicit substance abuse affects multiple area of
functioning and comorbid diagnosis occurs in
about 60-70% of patients with substance
related disorder
Substance abuse can mimic psychiatric
ilnesses include psychotic, anxiety, and
depression
 TYPE. I NARCOTIC
For knowledge not for therapy
High potention for addiction
Example -HEROIN
-COCCAIN
-CANABIS
 TYPE II NARCOTIC
For therapy and knowledge
High Potention for addiction
Example : -MORFIN
-PETHIDIN
 TYPE III NARCOTIC
For therapy and knowledge
Low potention for addiction
Example : CODEIN
 TYPE I PSYCHOTROPIC
For knowledge not for therapy

High potention for addiction

Hallucination effect

Hallucinogen : these include mescaline, psilocybin in

mushroom, LSD (Lysergic Acid Derivation)
MDMA (4methylen dioxyamphetamine)
 TYPE II PSYCHOTROPIC
For Therapy
High Potention , addiction
Efect : STIMULANS
Example : -AMFETAMIN,METHAMFETAMIN
-FENSYKLYDIN
-SEKOBARBITAL
-METYLFENIDAT
 TYPE III PSYCHOTROPIC
For therapy
Efek HYPNOTIC
EXAMPLE :-AMOBARBITAL
-FLUNITRAZEPAM
-BUPRENORFIN
-GLUTETIMID
-PENTAZOSIN
 TYPE IV PSYCHOTROPIC
For therapy
Low potention, addiction
Efect : ANXIOLYTIC
Example : -DIAZEPAM, NITRAZEPAM
-FENOBARBITAL
-ALPRAZOLAM
 TYPE V PSYCHOTROPIC
For Therapy
Efect : ANTIPSYCHOTIC, ANTIDEPRESAN, ANTI
MANIC, NOOTROPIC/NEUROTONIC
Example : - Antipsychotic : Haloperidol, Risperidon
- Antidepresant : Amytriptilin, Sertralin
- Anti mania: Lithium
- Neurotonic : Piracetam
 Addictive Substance
ALCOHOL
Type A : 1-5% : BIR, GREEN SANDS
B : 5-20% : ANGGUR
MARTINI
C : 20-55% : WISKI
BRANDI
TEQUILA
 ADDICTIVE SUBSTANCE
CAFFEINE : Coffee, Energic drink
NICOTINE
Inhalants these include solvents such as
toluene, gasoline and gases such as nitrous
oxide
 Terminologi
Dependence : repeated use of a drug or
chemical substance, with or without physical
dependence
Abuse : use of any drug by self administration,
that deviates from approved social and
medical pattern
Misuse : similar to abuse but usually applies
to drugs prescribed by physicians that are not
used properly
 Addiction : The repeated (compulsive) and
increase use of substance.
Intoxication (>> Dose) : a reversible syndrome
caused by a spesific substance that affects one or
more of the following mental functions : memory,
orientation, mood, judgement, behavior, social,
occupational
Withdrawal : A substance spesific syndrome that
occur after stopping or reducing the amount of
the drug or substance that has been used
regularly over a prolonged period of time
Psychodinamic

1. organo-biologik
genetic factor
Neurotransmitter defisit
2. Psychologic factor
oral phase fixation
antisocial personality
3. Sosio cultural/environment
Stress, unhappy family
black market
weakness of law regulation
 ETIOLOGIC

INDIVIDUAL ENVIRONMENT

SUBSTANCE
 INDIVIDUAL FACTOR
EXPERIMENTAL USE
LOW SELF ESTEEM
LOW SELF CONFIDENCE
ANTISOCIAL PERSONALITY
LOOKING FOR SELF IDENTITY
HAVING STRESOR/ PROBLEM
IMMATURE DEFENCE MECHANISM
RELIGY
BROKEN HOME
 GRADE OF DRUG USER
I. EXPERIMENTAL USE
II. SOCIAL USE/HAVING FUN/RECREATIONAL
USE
III. SITUATIONAL USE
IV. ABUSE
V. DEPENDENCE/TOLERANCE-WITHDRAWL
 Evaluation
Often difficult to detect and evaluate
They are often manipulative, denial, and fear
the consequences of acknowledging the
problem It is necessary to obtain
information from other sources
Substance abuse is frequently associated with
personality disorders (antisocial, borderline,
narcissistic)
1.Anamnesis : History ; continuous or episodic
2.Toxicology (urine, hair, blood test, saliva)
3. Physical examination
Subcutaneus or intravenous abusers : AIDS, scars,
abcess, infection, thrombophlebitis
Snorter of coccaine, heroin, other drugs :
deviated of nasal septum, nasal bleeding, rhinitis
Smokers of marijuana or other drugs, inhalant
abusers : bronchitis, asthma, chronic respiratory
condition
4. Psychometry : ASSIST, ASI
 Coccain
Effect : Stimulans
withdrawal :
1. fatique
2. Nigthmare
3. Insomnia
4. Retardation psychomotor
Therapy
Antidepresant
- Bupropion
- MAOI
- SSRI
- Fluoxetin
- Sertralin
 INTOXICATION
1. Tachycardia / brodycardia
2. pupillary dilation
3. Blood pressure /
4. Nausea and vomiting
5. Agitation
6. Chest pain, aritmia
7. Confusion , seizure

Therapy :
- Lithium
- Dilantin
 ALCOHOL
production of somnolence and decreased neuronal activity but
not powerful in attenuating pain

Potentially lethal in overdose, produce cross tolerance with other

depressants, physically addicting with withdrawal symptoms.

Neurochemical Effects of Ethanol

Changes in dopamine, tying in the effects of alcohol on pleasure
centers in ventra tegmental area of brain, actions on GABA-A
receptor enhance acure sedating, sleep, anticonvulsant, muscle
relaxing
 Tolerance
3 process: behavioral, pharmacokinetic, pharmacodynamic

Craving
Activation of limbic system, the orbitofrontal and insular cortex,
as well as in the cerebellum

Blackout
Memory impairment for the period when a person was drinking
heavily but remained awake
 Sleep impairment
Suppresses REM, inhibits stage 4 sleep, sleep fragmentation,
intense and disturbing dreams

Cerebellar degeneration
Unsteadiness of gait, mild nystagmus, problems with standing
steadiness

Other effects on the Central Nervous System

Wernickes and Korsakoffs Syndrome

Peripheral neuropathy
Numbness of extremities, tingling and paresthesias
 Gastrointestinal problems
Acute inflamation of esophagus/stomach, esophageal vein
bleeding, fatty liver, hepatitis, cirrohis, pancreatitis

Cerebrovascular and cardiovascular problems

Increase blood pressure, elevate LDL and TG, enhance risk MI and
thrombosis, alcoholic cardiomyopathy

Blood producing system

Decrease production of leucocyte, erythrocytes, impair platelets

Cancer
Tumors of head neck esophagus stomach, liver, colon, lungs,
breast
 Fetal Acohol Effects
Fetal death, spontaneous abortion, mental retardation, small
head, low birth weight, facial abnormalities, atrial septal defect,
syndactyly

Other problems
Testicular atrophy, bone fractures, cataracts, dental difficulties,
muscle wasting, increase risk of accident
 1. Intervention
Principles of motivational interviewing to break through denial
and help patient recognize the adverse conseqences for drinking
alocohol.

2. Detoxification and Rehabilitation

First step is a thorough physical examination to find out serious
medical disorders

Second step is to offer rest, adequate nutrition, oral multiple

vitamis, especially Thiamine
 Medications
1. Acamprosate analog of amino acid neurotransmitter
taurine, structurally resembles GABA. 2000 mg/day

2. Naltrexone long acting, oral, opioid antagonist.

15-20% better outcomes than placebo. 50-150 mg/day or
injection 380 mg.

3. Disulfiram-the alcohol-sensitizing agent. Many side effects:

mood swings, psychosis, possibility an increase of peripheral
neuropathy, rare fatal hepatitis.

4. Topiramate-anticonvulsant
5. Ondansentron-serotonin 3 receptor antagonist
6. SSSRI, GABA-B receptor agonist Baclofen
7. antipsychotic
OPIOID

DSM-IV-TR divides opioid-related disorders into

opioid use disorders (opioid abuse and opioid
dependence) and nine other opioid-induced
disorders (e.g intoxication and withdrawal).
The person often continues to use drugs despite
wanting to quit and despite being aware of
adverse medical, social, and psychological
sequence from their drug-using behavior.
 Definition
The opioid- induced disorders as defined by
DSM-IV-TR include such common
phenomenon such as opioid intoxication,
opioid withdrawal, opioid-induced sleep
disorder and opioid-induced sexual
dysfunction.
 Opioid dependence
Depression (usually either major depression
or substance-induced mood disorder) is the
most common disorder.
Suicidal ideation (thoughts) and insomnia.
Other substance use disorders (such as
alcoholism), anxiety disorders, antisocial
personality disorder, post-traumatic stress
disorder , and a history of conduct disorder
are also fairly common.
 Opioid intoxication
Intoxication on other substances, such as alcohol,
sedatives, hypnotics, and anxiolytics, can
resemble intoxication on opioids. Furthermore,
dilated pupils can be seen in hallucinogen
intoxication, amphetamine intoxication, and
cocaine intoxication. Therapy : naloxone injectie
Withdrawal :
The restlessness and anxiety seen in opioid
withdrawal is also seen in withdrawal from
sedatives, hypnotics, and anxiolytic. Therapy :
Substitusi methadon, buprenorfin
 SYMPTOMS

WITHDRAWAL INTOXICATION
Opioid Pain Drowsiness coma
Nausea, Vomiting Slurred speech
diarrhea Impairment attention
Insomnia or memory
Anxiety Pupillary constriction
Pupillary dilation Blood pressure
Fever Respiration rate
Respiration rate Heart rate
Heart rate Behavioral
Dysphoric mood psychological change
restlessness
 Differential Diagnosis

Opioid-induced
Opioid Induced Opioid Induced
Psycotic
Mood Disorder Sleep Disorder
Disorder
 Treatment (1)
Self-
help
groups.
Individualiz Methadone
ed drug maintenance
counseling. treatment

Supportive- Opioid
expressive
psychothera
antagonist
py . treatment

Opioid
Outpatient
agonist-
drug-free
treatment. antagonist
treatment.
 AMPHETAMINE (OR AMPHETAMINE-LIKE)
In addition to amphetamine itself, some members of this
class include:
- methamphetamine (METH)
- methcathinone, phentermine,
- methylenedioxyamphetamine (MDA)
- 3,4-methylenedioxymethamphetamine (MDMA)
- methylenedioxyethylamphetamine (MDEA)
Have classic psychostimulant properties

Amphetamine-like, example:
- methylphenidate
- caffein
 DEFINITION
The individual must have a history of at least 3 of 7:
Tolerance
Withdrawal
Greater use of drug than intended
Inability to cut back on use
A great deal of time using drug
A reduction in social, occupational, or recreational
activities
Continued use despite being aware that use is
associated with problem
 PHARMACOLOGY
The drugs produced acute psychomotor
stimulant effect
The pharmacokinetics of METH are dependent
on route of administration and dose.
Regardless of the route of administration, the
reinforcing effects of METH:
Euphoria
Power and confidence
Decreased need for sleep
Increased energy and concentration.
 DIAGNOSIS AND CLINICAL FEATURES
AMPHETAMINE INTOXICATION
Diagnostic criteria:
A. Recent use of amphetamine or a related substance
B. Clinically significant maladaptive behavioral or psychological
changes that developed during, or shortly after use of
amphetamine or a related substance
C. 2 (or more) of the following, developed during, or shortly after
use of amphetamine or a related substance
1) Tachycardia or bradycardia
2) Pupillary dilation
3) Elevated or lowered blood pressure
4) Perspiration or chills
5) Nausea or vomiting
6) Evidence of weight loss
 DIAGNOSIS AND CLINICAL FEATURES
AMPHETAMINE WITHDRAWAL
Diagnostic criteria:
A. Cessation of (or reduction) amphetamine (or related substance) use that
has been heavy and prolong
B. Dysphoric mood and two (or more) of the following, developing within a
few hours to several days after criteria A.
1) Fatigue
2) Vivid, unpleasant dreams
3) Insomnia or hypersomnia
4) Increased appetite
5) Psychomotor retardation or agitation
C. The symptom of criteria B cause significant distressnor impairment in
social, occupational, or other important areas of function
D. The symptoms are not due to a general medical condition and are not
better accounted for by another mental disorder.
 DIAGNOSIS AND CLINICAL FEATURES

AMPHETAMINE INDUCED SEXUAL DYSFUNCTION

In chronic abuse : diminished several abilities, loss of
libido, an impotence

AMPHETAMINE INDUCED SLEEP DISORDERS

Withdrawal: hypersomnolence that can persist for weeks

AMPHETAMINE RELATED DISORDER NOT OTHERWISE

SPECIFIED
 symptoms

WITHDRAWAL INTOXICATION
Amphetamin fatigue Tachycardia/Bradycardia
(stimulan) Depresion Pupilary dilation
Hipersomnia Elevated blood pressure
Appetite Sweating
Nightmare Nausea, vomiting
Inability in Weight loss
concentration Depressed breath
Chest pain
 TREATMENT
Psychological and behavioral treatment
approaches are the primary modality
Pharmacotherapy:
Bupropion, in combination with behavioral group
therapy
Antidepresan (withdrawal)
Mood stabilizer (manic)
Modafinil
Gamma-vinyl GABA
 BENZODIAZEPIN
INTOXICATION
Benzodiazepine intoxication can be associated
with behavioral disinhibition, potentially
resulting in hostile or aggressive behavioral.
Combine with alcohol intoxication.
Benzodiazepine intoxication is associated with
less respiratory depression than barbiturate
intoxication.
 WITHDRAWAL SYNDROME
The discontinuance syndrome may also be
divided into symptoms of :
Rebound
Recurrent
Withdrawal
Rebound Symptoms : those for which the
benzodiazepine was originally prescribed that
return in a more severe form than they had
before treatment.
Recurrent Symptoms : return of the original
symptoms at or below their original intensity.
 WITHDRAWAL SYNDROME
Disturbances of mood and cognition
Anxiety, apprehension, dysphoria, pessimism,
irritability, obsessive rumination, and paranoid
ideation.
Disturbances of sleep
Insomnia, altered sleep-wake cycle, daytime
drowsiness
 WITHDRAWAL SYNDROME
Physical sign and symptoms
Tachycardia, elevated blood pressure,
hyperreflexia, muscle tension, agitation,
tremor, myoclonus, muscle and joint pain,
nausea, coryza, diaphoresis, ataxia, tinnitus,
and grand mal seizure.
Perception disturbances
Hyperarcusis, depersonalisasi, blurred vision,
illusions, halusinasi.
 RISK FACTOR
Dosage of benzodiazepine
Duration of benzodiazepine treatment
Rate of drug taper
Psychopathology (score MMPI-2 higher, high
prewithdrawal level of anxiety and depression,
lower educational level, and passive
dependent personality disorder).
 sYMPTOMS
INTOXICATION WITHDRAWAL
Alcohol Maladaptive behavior and Autonomic hyperactivity
psychological change Insomnia
Slurred speech Increased hand tremor
Incoordination Nausea and vomiting
Unsteady gait Transient hallucination
Nystagmus Psychomotor agitation
Impairment memory or Anxiety
attention Grandmal seizure
Stupor or Coma Delirium Tremens (DTs)

Benzodiazepine Drowsiness Anxiety

(sedative lethargy, Insomnia
hypnotic) ataxia, Nightmare
confusion, Grandmal seizure
minimal decrease of vital Psychosis
sign Hyperpyrexia
Death
 CANNABIS
Pharmacology of cannabinoid
THC is the is the primary psychoactive
constituent in cannabis
Two kinds of receptor of cannabinoid, CB1 and
CB2
- CB1 : CB1 receptors is found primarily in the brain
and mediates the pdsychological and behavioral
effects of THC
- CB2 : CB2 receptor is associated with the immune
system and appears to modulate inflammatory
response
 Intoxication
Most people use cannabis in order to experienced
a high, characterized by euphoria, relaxation and
perceptual alteration including time distortion,
and the intensification of ordinary experiences
such as eating, watching films, listening to music,
and engaging in sex.
Cognitive changes include impaired short-term
memory and attention that make it easy for the
user to become lost in pleasant reverie and
difficulties to sustain goal-oriented mental activity.
Motor skills, reaction time, other psychomotor
activity are impaired
 Cannabis and Schizophrenia
There are some evidence stating that the use of
cannabis can precipitate schizophrenia in
vulnerable individuals
Psychotic disorders involve disturbances in
dopamine neurotransmitter. THC is known to
increase dopamine secretion
A research in British found that individuals with
history of heavy chronic cannabis use who
developed psychosis were ten times more likely to
have family histories of schizophrenia.
 Anxiety Induction
Some users report increased anxiety level,
panic, the fear of being angry, and
depression after using cannabis
There is an increased in heart rate by 20-
50% only in minutes after the use
Postural hypotension may occur
Withdrawal
Withdrawal symptoms could be manifested as
anxiety, insomnia, irritable, apettite
disturbance, and depression
 SYMPTOMS

INTOXICATION WITHDRAWAL
Canabis : euphoria anxiety,
Marijuana perceptual alteration Insomnia
Hasish intensification of Irritable
Ganja ordinary experiences apettite disturbance
such as eating, depression.-
watching films,
listening to music,
and engaging in sex.
Withdrawal :
Nicotine
Withdrawal :
1. dysphoric
2. Insomnia
3. angry
4. anxiety
5. Concentration difficulties
6. Agitation
7. Palpitation
8. Increase Appetite
Therapy
Nicotine replacement therapies
- Nicotine gum (nicorette)
- Nicotine patches (nicoderm)
- Nicotine nasal spray (nicotrol)
Non nicotine bupropion (zyban)
Clonidine
Psychoterapi
Hypnoterapi
 Caffein
Effect Psychostimulans, diuretic
blood pressure
Withdrawal :
1. Fatique
2. Anxiety
3. Nausea and vomiting
Intoxication
1. Anxiety
2. Insomnia
3. diuresis
4. Muscle twitching
5. Tachycardia
6. Agitation
7. Rambling flow of thought and speech
 Halusinogen
Intoxication
1. halusination, ilusi, depersonalisation, derealisation
2. Two or more symptoms :
- Pupillary dilation
- Tachycardia
- sweating
- Palpitation
- Blurred vision
- Tremor
- Incoordination
Therapy
Benzodiazepin clonazepam
Anti convulsant : valproic acid, carbamazepine
COMORBIDITIES
SCHIZOPHRENIA
MANIC
DEPRESSION
BIPOLAR DISORDER
MENTAL RETARDATION
CONDUCT DISORDER
PERSONALITY DISORDER
THANK YOU