Substance abuse, Acute Stress Disorder & Conduct disorder

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Substance Dependence

Things you should know

• Use of one or more substances leads to a clinically significant impairment or distress

Signs and Symptoms

• See Diagnosis below

Diagnosis

• Physical assessment
• Laboratory test
  • Toxicology screening – using either blood or urine sample
• Psychological assessment using Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
  • One may have a substance use disorder if at least two of these issues occur within a 12-month period:
    • Tolerance – Takes larger amounts of the drug over a longer period of time than intended
    • Failed attempts and unable to stop using the drug
    • Spends a good deal of time getting the drug, using the drug or recovering from the effects of the drug
    • With intense urges for the drug that block out any other thoughts
    • Unable to meet obligations and responsibilities because of substance use
    • Keeps using the drug, despite awareness that it’s causing problems
    • Gives up or cuts back important social, occupational or recreational activities because of substance use
    • Uses the substance in situations that may be unsafe, such as when driving or operating machinery
    • Uses the substance despite knowing it causes physical or psychological harm
    • Experiences physical or psychological withdrawal symptoms on attempts to stop taking the drug
    • Takes the drug (or a similar drug) to avoid withdrawal symptoms

Treatment

• Detoxification
  • Goal: stop taking the addicting drug as quickly and safely as possible
  • “Detox” or Withdrawal Therapy
  • May involve gradually reducing the dose of the drug or temporarily substituting other substances, such as methadone
  • Tailoring Treatment
• Counselling
  • Talk therapy or psychotherapy
  • Done by a psychologist, psychiatrist, or licensed drug counselor with an individual, family or group.
• Self-help groups
  • Alcoholics Anonymous
  • Narcotics Anonymous
  • The self-help support group message is that addiction is a chronic disorder with a danger of relapse.
  • Can decrease the sense of shame and isolation that can lead to relapse

Substance Withdrawal

Things you should know

• A group of symptoms that occur upon the abrupt discontinuation or decrease in intake of medications or recreational drugs

Signs and Symptoms

• Mild
  • Intense worry
  • Nausea or vomiting
  • Shakiness
  • Sweating
  • Restlessness/Feeling a little tense or edgy
  • Poor concentration
  • Headaches
  • Irritability
• Severe
  • Being extremely confused, jumpy, or upset
  • Hallucinations (visual, audio, tactile)
  • Severe trembling
  • Insomnia
  • Depression
  • Social Isolation
  • Palpitations
  • Muscle tension
  • Chest pain
  • Difficulty breathing
  • Tremors
• Life-threatening
  • Grand mal seizures
  • Heart attacks
  • Strokes
  • Hallucinations
  • Delirium tremens (DTs) – begin about 3 days after last drink

Diagnosis

• Thorough physical and detailed history

Treatment

• Goals of treatment:
  • Reduce immediate withdrawal symptoms
  • Prevent complications
  • Beginning long-term therapy to promote abstinence.
• Medications
  • Prescription drugs of choice:
    • Benzodiazepines – for alcohol withdraw
      • Diazepam (Valium)
      • Chlordiazepoxide (Librium)
      • Lorazepam (Ativan)
      • Oxazepam(Serax).
    • Antipsychotic drug – to help relieve agitation and hallucinations
    • Beta-blocker
      • to treat tachycardia and elevated blood pressure related to withdrawal
      • reduce the strain of alcohol withdrawal in people with coronary artery disease
• 12-Step Group
  • Alcoholics Anonymous
  • Narcotics Anonymous
• Cognitive and Behavioral therapy
• Family Therapy

Acute Reaction to Stress (Acute Stress Disorder)

Things you should know

• A psychological condition arising from a mentally healthy individual in response to a terrifying or traumatic event
• Psychological shock
• Lasts from 3 days to 1 month. If symptoms persist past 1 month, diagnosis is changed to Posttraumatic Stress Disorder

Symptoms

• See Diagnosis below

Diagnosis

• Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
  • Directly experiencing the traumatic event
  • Witnessing, in person, the event as it occurred to others.
  • Learning that the traumatic event occurred to a close family member or close friend.
  • Experiencing repeated or extreme exposure to aversive details of the traumatic event, such as first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
• Presence of nine (or more) of the following symptoms from any of the five categories:
  • Intrusion Symptoms
    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event
    • Recurrent distressing dreams
    • Dissociative reactions, such as flashbacks
  • Negative Mood
    • Persistent inability to experience positive emotions
  • Dissociative Symptoms
    • An altered sense of the reality of one’s surroundings or oneself, such as seeing oneself from another’s perspective, being in a daze, time slowing
    • Inability to remember an important aspect of the traumatic event
  • Avoidance Symptoms
    • Efforts to avoid distressing memories, thoughts, or feelings
    • Efforts to avoid external reminders
  • Arousal Symptoms
    • Sleep disturbance
    • Irritable behavior and angry outbursts
    • Hypervigilance
    • Problems with concentration
    • Exaggerated startle response

Treatment

• Psychological Treatment
  • Cognitive prolonged exposure
  • Behavioral exposure to safe situations which illicit fear.
  • Eye movement desensitization and reprocessing (EMDR)
• Pharmacological Treatment
  • Antidepressant Medication:
    • Recommended as first-line medication treatment for Acute Stress Disorder
      • Selective serotonin reuptake inhibitor (SSRI)
      • Tricyclic
      • Monoamine Oxidase Inhibitor (MAOI)
  • Benzodiazepines:
    • May be useful in reducing anxiety and improving sleep
    • Carry a high risk for dependence

Conduct Disorder

Things you should know

• Childhood diagnosis otherwise see antisocial personality disorder
• Repetitive pattern behavior in which the basic rights of others or major age-appropriate norms are violated
• Causes
  • Biological
  • Genetics
  • Environmental
    • Dysfunctional family life
    • Childhood abuse
    • Traumatic experiences
    • A family history of substance abuse
    • An inconsistent discipline by parents
• Prevalence rate among incarcerated youth or youth in juvenile detention facilities: 23% and 87%
• More common in boys than in girls
• Often occurs in late childhood or the early teen years

Symptoms

• Aggressive behavior
  • Threats or causes physical harm
    • fighting
    • bullying
    • being cruel to others or animals
    • use of weapons
    • forcing another into sexual activity
• Destructive behavior
  • Intentional destruction of property
    • Arson
    • Vandalism
• Deceitful behavior
  • Lying
  • Shoplifting
• Violation of rules
  • Going against accepted rules of society or engaging in behavior that is not appropriate for the person’s age
    • Running away
    • Skipping school
    • Playing pranks
    • Being sexually active at a very young age
• Irritable
• Low self-esteem
• Tends to throw frequent temper tantrums
• Drug and alcohol abuse
• Inability to appreciate how their behavior can hurt others
• Generally have little guilt or remorse about hurting others

Diagnosis

• Diagnostic basis: prolonged pattern of antisocial behaviour such as serious violation of laws and social norms and rules
• DSM-5 criteria for conduct disorder categories:
  • aggression to people and animals
  • destruction of property
  • deceitfulness or theft
  • serious violation of rules

Treatment

• Multisystemic Treatment
  • An intensive, integrative treatment that emphasizes how an individual’s conduct problems fit within a broader context.
  • The individual is viewed functioning within a series of interconnected systems that reinforces their behavior.

Study Tips

Attitude is extremely important!

Key Terms and Ideas

• A patient exhibits behavior that fits the diagnosis of conduct disorder, but he is 20 years old.  What is the diagnosis?
  • Antisocial personality disorder
• How long after a patient enters the hospital may Delirium Tremens begin
  • 2-3 days.
• How long do symptoms have to occur for the diagnosis of acute stress reaction to change to post traumatic stress disorder?
  • 1 month