The toxic effects of substances can mimic mental illness in ways that can be difficult to distinguish from mental illness. This chapter focuses on symptoms of mental illness that are the result of substance abuse—a condition referred to as “substance-induced mental disorders.”
Here is that list again to better follow in the days to come and as we get started today:
• Alcohol
• Caffeine
• Cannabis, Cocaine and Amphetamines
• Hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, and other hallucinogens, such as LSD)
• Nicotine
• Opioids
• Sedatives
• Inhalants
• Hypnotics or anxiolytics
• Stimulants (including amphetamine-type substances, cocaine, and other stimulants)
Substance-induced disorders are distinct from independent co-occurring mental disorders in that all or most of the psychiatric symptoms are the direct result of substance use.
This is not to state that substance-induced disorders preclude co-occurring mental disorders, only that the specific symptom cluster at a specific point in time is more likely the result of substance use, abuse, intoxication, or withdrawal than of underlying mental illness. A client might even have both independent and substance-induced mental disorders.
For example, a client may present with well-established independent and controlled bipolar disorder and alcohol dependence in remission, but the same client could be experiencing amphetamine-induced auditory hallucinations and paranoia from an amphetamine abuse relapse over the last 3 weeks.
Symptoms of substance-induced disorders run the gamut from mild anxiety and depression (these are the most common across all substances) to full-blown manic and other psychotic reactions (much less common). The “teeter-totter principle”—i.e., what goes up must come down—is useful to predict what kind of syndrome or symptoms might be caused by what substances.
For example, acute withdrawal symptoms from physiological depressants such as alcohol and benzodiazepines are hyperactivity, elevated blood pressure, agitation, and anxiety (i.e., the shakes). On the other hand, those who “crash” from stimulants are tired, withdrawn, and depressed. Virtually any substance taken in exceptionally large quantities over a long enough period can lead to a psychotic state.
Since clients vary in how they respond to both intoxication and withdrawal given the same exposure to the same substance, and because different substances may be taken at the same time, prediction of any substance-related syndrome has its limits. What is most important is to continue to evaluate psychiatric symptoms and their relationship to abstinence or ongoing substance abuse over time.
Most substance-induced symptoms begin to improve within hours or days after substance use has stopped. Notable exceptions to this are psychotic symptoms caused by heavy and long-term amphetamine abuse and the dementia (problems with memory, concentration, and problem solving) caused by using substances directly toxic to the brain, which most commonly include alcohol, inhalants like gasoline, and again amphetamines.
The following is an overview of the most common classes of substances of abuse and the accompanying psychiatric symptoms seen in intoxication, withdrawal, or chronic use.
ALCOHOL: What does an Alcohol use disorder mean?
There really is no official diagnosis of alcoholism. The condition that has long been termed alcoholism is technically called “severe alcohol use disorder,” according to the May 2013 publication of the 5th edition of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM–5) by the American Psychiatric Association. With the DSM-5, if a person exhibits two or more symptoms from a list of 11 criteria, they are diagnosed as having an alcohol use disorder, with classifications of mild, moderate, and severe.
The DSM-IV (published in 1994) likewise had no “alcoholism” diagnosis but instead described two distinct disorders—alcohol abuse and alcohol dependence—with specific criteria for each diagnosis. The DSM-5 combines those two disorders into one alcohol use disorder with sub-classifications of severity.
Alcohol Use Disorder Severity: When a person is diagnosed with alcohol use disorder, the severity of the condition is determined by the number of symptoms they have.
• Mild: 2-3 symptoms present
• Moderate: 4-5 symptoms present
• Severe: 6 or more symptoms present
Although there is a lot of overlap between the criteria (list of symptoms) used by the DSM-IV and the DSM-5, there are two significant changes. The DSM-5 eliminates having legal problems as a result of drinking as a criterion for diagnosis but adds craving for alcohol as a criterion.
What are some of the symptoms of an Alcohol Use Disorder?
According to the National Institutes of Health, an alcohol use disorder (AUD) is defined as a “chronic relapsing brain disease” that causes a person to drink compulsively despite adverse consequences to daily life and overall health. Alcohol use disorder replaced the designations previously defined as “alcohol abuse” and “alcohol dependence.”
Symptoms Listed in (Diagnostic and Statistical Manual of Mental Disorders) DSM-5. The DSM-5 lists 11 symptoms that can be used to determine if someone has an alcohol use disorder:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent on activities necessary to obtain alcohol, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect, or b) A markedly diminished effect with continued use of the same amount of alcohol.
Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
Roughly 15 million people in the United States were diagnosed with an AUD in 2018, including 19.2 million men, 5.3 million women, and 401,000 adolescents ages 12–17.
To be diagnosed with an AUD, individuals must experience two of the 11 criteria of AUD as outlined by the DSM-5 during the same 12-month period.
Here is a quick summary of the above criteria:
• Drinking more than intended
• Trying to quit without success
• Increased alcohol-seeking behavior
• Missing work or school due to drinking
• Interference with important activities
• Craving for alcohol
• Drinking despite social or personal problems
• Continued use despite health problems
• Drinking in hazardous situations
• Buildup of tolerance
• Withdrawals when trying to quit
Causes and Risk Factors of an Alcohol Use Disorder:
An alcohol use disorder can result from a combination of genetic, environmental, psychological, and social factors, many of which are still being researched.
Some of the most common risk factors include:
• Heavy, chronic drinking: Drinking too much alcohol has been found to alter the parts of the brain responsible for pleasure, judgment, and self-control, which can cause alcohol cravings.
• Family history: Children of parents with an alcohol use disorder are two to six times more likely than the general public to develop an AUD. This increased risk is due to genetics as well as environmental and lifestyle influences shared by members of the family.
• History of trauma: Childhood trauma, including emotional abuse, sexual abuse, physical abuse, emotional neglect, and physical neglect, have all been linked to an increased risk for an AUD in adulthood.
• Psychiatric disorders: People with a mental health disorder such as anxiety, depression, schizophrenia, and bipolar disorder have been found to have higher rates of misusing alcohol or other substances. In fact, studies show that over one-third of patients with schizophrenia meet the criteria for an AUD diagnosis.
• Social and cultural influences: Having parents, peers, partners, and other role models who drink regularly may increase a person’s risk of developing an AUD, especially if the person is exposed to heavy drinking at a young age.
Another crucial factor that influences the risk of alcohol on the body is nutrition. Alcohol and nutrition can interact in a number of ways—heavy alcohol use can interfere with nutrition while alcohol/nutrition interactions can impact gene expression.
TREATMENT:
The good news is that most people with AUD can benefit from treatment, which often includes a combination of behavioral treatment, medication, and support. The bad news is that less than 10% of people actually receive treatment, often due to fear of stigma or shame, denial or lack of problem awareness, skepticism about treatment, and lack of accessibility to affordable treatment.
If left untreated, alcohol use disorders can be harmful to your health, relationships, career, finances, and life. They can even be fatal, so it’s important to get help as early as possible.
A good first step is talking to your primary care physician, who can assess your overall health, evaluate the severity of your drinking, help craft a treatment plan, refer you to an addiction specialist or treatment program, and determine if you need any medications for alcohol.
DETOX & WITHDRAWL:
Depending on the severity of your AUD, you may need to undergo medical detox to help treat the symptoms of alcohol withdrawal, which can range from mild to severe. Detox can be done on an in-person or outpatient basis and include intravenous (IV) fluids to prevent dehydration and medications to minimize symptoms and treat seizures or other complications of alcohol withdrawal.
How to Gauge the Severity of Alcohol Withdrawal Symptoms:
Symptoms of alcohol withdrawal can occur when you suddenly stop using alcohol after regular excessive drinking and can range from severe to mild. Severe withdrawal symptoms can be serious and in rare situations, fatal.
Because they can worsen over time, it is important to know whether your symptoms are getting more severe so you can seek help. The most severe symptoms usually occur between two and five days after you stop drinking, which means that the first day or two may not be a good indicator of your risk of serious problems.
MODERATE vs. EXCESSIVE DRINKING:
The Centers for Disease Control and Prevention (CDC) defines moderate drinking as up to one drink per day for women and up to two drinks per day for men. Moderate drinking is considered safe for most people over the age of 21.
A drink is generally defined as:
• 12 ounces of beer
• 8 ounces of malt liquor
• 5 ounces of wine
• 1.5 ounces of 80-proof distilled liquor or spirits, such as whiskey, gin, rum, or vodka
Excessive drinking is defined by the CDC as heavy drinking, binge drinking, or drinking that’s done by anyone who is pregnant or under the age of 21. Binge drinking means consuming multiple drinks during one occasion. For women, that’s four or more drinks and for men, it’s five or more.
Heavy drinking occurs when women have eight or more drinks a week and men have 15 or more drinks per week. The majority of people who drink excessively do not have an alcohol use disorder and/or are not dependent on alcohol.
HOW WITHDRAWAL WORKS:
If you are a heavy drinker—even if you are not an alcoholic—you are likely to experience at least some symptoms if you stop drinking suddenly. Most people use alcohol to relieve anxiety and relax.
Alcohol provides this outcome by increasing the effects of GABA, a neurotransmitter responsible for creating feelings of calm and euphoria. It also decreases glutamate, another neurotransmitter that creates excitability.
Heavy drinking makes it harder and harder to increase GABA and decrease glutamate, so increased alcohol is required for the same outcome. Your body becomes accustomed to these changes and responds by producing more glutamate and less GABA.
When you suddenly stop drinking, you are no longer impacting these two neurotransmitters, but your body is still over producing glutamate and under producing GABA.
As a result, you may become hyper excited: anxious, restless, and shaky. If you were a heavy drinker, your symptoms may be much more severe, progressing to tremors, seizures, and serious high blood pressure.
COMMON WITHDRAWAL SYMPTOMS:
If you have been regularly drinking excessively and you stop drinking suddenly, you may experience one or more alcohol withdrawal symptoms. Depending on your past alcohol use, these symptoms can range from mild and uncomfortable to severe and potentially life-threatening.
Though symptoms typically begin within eight hours after your last drink, you may not experience any until several days later. These symptoms tend to spike around 24 to 72 hours (about 3 days) after your last drink, though milder ones may persist for much longer in some people.
Common symptoms include:
• Feeling anxious or nervous
• Feeling irritable
• Feeling depressed
• Feeling wiped out and tired
• Shakiness
• Mood swings
• Not being able to think clearly
• Having nightmares
• Dilated pupils
• Sweating
• Headache
• Difficulty sleeping
• Nausea and/or vomiting
• Appetite loss
• Faster heart rate
• Pale skin
• Tremor
SEVERE WITHDRAWAL SYMPTOMS:
One of the most severe consequences of alcohol withdrawal is called delirium tremens, or “the DTs.” About 3% to 5% of people who withdraw from heavy drinking experience delirium tremens. This condition can become fatal if it’s left untreated, so if you or a loved one show any symptoms of the DTs, seek emergency treatment because symptoms can get worse.
Symptoms of delirium tremens include:
• Fever
• Extreme agitation
• Seizures
• Extreme confusion
• Hallucinations (feeling, seeing, or hearing things that aren’t there)
• High blood pressure
Hospitals and detox centers have experienced staff who are familiar with these symptoms and have the tools to provide appropriate treatment.
The majority of people experience a full recovery from alcohol withdrawal symptoms. Some people continue to have disruptive symptoms known as post-acute withdrawal for months such as difficulty sleeping, fatigue, mood swings, and fatigue. A small percentage of people die from delirium tremens.
If you have underlying medical conditions, you continue to drink heavily, and/or your organs are damaged, your recovery will be more complicated. Heavy drinking damages your organs and can lead to heart disease, liver disease, and nervous system problems, so it is important to get help and treatment if you are having a tough time abstaining from using alcohol.
BEHAVIORAL TREATMENT:
A big part of AUD recovery is working with a trained professional to better understand your relationship with alcohol and to learn how to cope with daily living without alcohol. Behavioral treatment can also help with any co-occurring mental illnesses contributing to the AUD.
• Cognitive behavioral therapy: aims to teach you to recognize and avoid the situations in which you are most likely to drink and to cope with other problems and behaviors that may lead to alcohol misuse.
• Motivational enhancement therapy aims to help you build your confidence and motivation to stop drinking.
• Family therapy: aims to help families become aware of their own needs and prevents substance misuse from moving from one generation to another.
• Brief interventions: aims to get the person to reduce their level of drinking or change their harmful pattern of drinking.
MEDICATIONS:
There are three medications approved by the FDA for treating an alcohol use disorder. While not all people will respond to medication, many find it helpful in reducing cravings and maintaining abstinence, especially when combined with behavioral treatment and support.
• Naltrexone (Revia, Depade, Vivitrol): reduces the craving for alcohol
• Acamprosate (Campral): reduces post-acute withdrawal symptoms during the initial stages of alcohol abstinence
• Disulfiram (Antabuse): causes unpleasant symptoms such as flushing, nausea, vomiting, and headache when you drink alcohol
IN CLOSING: Folks, these diagnoses are real, and millions suffer from these addictions every day. If you suspect that you or someone you love has an alcohol use disorder, your healthcare provider can conduct a formal assessment of your symptoms. There is always help, you just must be the one to ask as hard as that is for so many.
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