Addiction and Substance Use Disorder Mnemonics (Memorable Psychiatry Lecture)
Summary
TLDRThe video script delves into the prevalence of psychoactive substance use, detailing intoxication, withdrawal, and addiction as separate yet interconnected issues. It outlines the DSM-5 criteria for substance use disorders and introduces the 'three reapers' model for diagnosing addiction. The script also addresses the variability in addiction, its societal impact, and the importance of individualized treatment, including detoxification, rehabilitation, and motivational interviewing. It emphasizes the significance of social support and community in overcoming addiction.
Takeaways
- 🌟 **Commonality of Substance Use**: Over 90% of people in the United States use psychoactive substances regularly.
- 🚫 **Problems from Substance Use**: While many can use substances without harm, a minority develop issues such as intoxication, withdrawal, and addiction.
- 🔑 **Understanding Intoxication**: Intoxication is an acute state of being under the influence of a substance, with specific signs and symptoms known as a toxodrome.
- 🔄 **Withdrawal Symptoms**: Withdrawal occurs when stopping a substance, leading to physiological and psychological effects, often opposite to those seen in intoxication.
- 🔗 **Addiction as a Chronic Condition**: Unlike intoxication and withdrawal, addiction is a chronic condition marked by repeated use despite negative consequences, known as substance use disorder.
- 📋 **DSM-5 Criteria for Substance Use Disorders**: The DSM-5 lists 11 criteria for diagnosing substance use disorders, with two or more required for diagnosis.
- 🔑 **The Three Reapers of Addiction**: Addiction can be recognized by repeated use, positive reinforcement, and negative repercussions.
- 🚫 **Distinguishing Addiction from Compulsion**: Addiction involves positive reinforcement, while compulsions are driven by negative reinforcement, requiring different treatment approaches.
- 👨⚕️ **Clinical Tools for Diagnosis**: Clinicians can use mnemonics like 'TRAPPED' for substance history and 'THIS GUY' for major classes of addictions to aid in diagnosis.
- 🌐 **Societal Impact of Addiction**: Addiction is a leading cause of death and societal costs, with less than 20% of those affected receiving quality treatment.
Q & A
What is the prevalence of psychoactive substance use in the United States?
-Over 90% of people in the United States take at least one psychoactive substance on a regular basis.
How are intoxication, withdrawal, and addiction different from each other?
-Intoxication is an acute state of being under the influence of a substance with specific signs and symptoms. Withdrawal involves physiological and psychological effects of stopping a substance, often opposite to intoxication. Addiction is a chronic condition characterized by repeated use despite negative consequences.
What are the 11 criteria for substance use disorders according to the DSM-5?
-The DSM-5 lists 11 criteria for substance use disorders, which can be remembered using the phrase 'Time to Cut Down, Pal', indicating that two or more of these criteria are required for diagnosis. The criteria include spending a lot of time using or obtaining the substance, experiencing cravings, inability to cut down, tolerance, dangerous use, social and interpersonal problems, withdrawal, neglecting responsibilities, and giving up activities due to substance use.
What are the 'three reapers' that characterize addiction?
-The 'three reapers' that characterize addiction are repeated use, positive reinforcers, and negative repercussions. All three components must be present for a diagnosis of addiction.
What is the significance of the mnemonic 'TRAPPED' in gathering a substance history?
-The mnemonic 'TRAPPED' stands for Treatment history, Route of administration, Amount used, Pattern of use, Prior abstinence, Effects of use (both positive and negative), and Duration of use. It is a tool to help clinicians gather a comprehensive substance history.
What does the phrase 'This guy's having trouble, but can his dog behave' represent in the context of addiction?
-The phrase 'This guy's having trouble, but can his dog behave' is a mnemonic to remember the major classes of addictions: Tobacco, Hallucinogens, Alcohol, Nicotine, Inhalants, Stimulants, Depressants, Opioids, Gambling, and other Behavioral addictions.
What is the lifetime prevalence of addiction in the United States?
-The lifetime prevalence of addiction in the United States is around 10%, making it one of the most common psychiatric conditions.
Why are men treated for addictive disorders more often than women, despite similar vulnerability?
-Men are treated for addictive disorders more often than women because they tend to use illegal substances more frequently, which are more likely to come to legal or clinical attention.
How does the presence of a dual diagnosis affect the prognosis for addiction and mental disorders?
-The presence of both an addiction and a mental disorder, known as dual diagnosis, worsens the prognosis for both types of disorders considerably.
What is the role of social support in the treatment of addiction?
-Social support is considered one of the most important, if not the most important, predictors of successful treatment for addiction. The opposite of addiction is not just sobriety but connection in community.
What is the significance of motivational interviewing in addiction treatment?
-Motivational interviewing is a counseling technique used to increase a patient's motivation to treat their addiction by matching interventions to the patient's stage of change, which has been found to be very effective with large effects compared to treatment as usual.
Outlines
🌟 Understanding Substance Use and Addiction
This paragraph discusses the prevalence of psychoactive substance use, highlighting that over 90% of people in the United States use such substances regularly. It differentiates between intoxication, withdrawal, and addiction, explaining each as separate but related conditions. Intoxication is described as an acute state with specific symptoms (toxodrome), withdrawal as the physiological and psychological effects of stopping a substance, and addiction as a chronic condition involving repeated use despite negative consequences. The paragraph also introduces the DSM-5 criteria for substance use disorders, suggesting the mnemonic 'TIME TO CUT DOWN PAL' to remember the key indicators. The concept of the 'three reapers' is introduced as a simplified way to recognize addiction: repeated use, positive reinforcement, and negative repercussions.
🔍 Distinguishing Addiction from Compulsion
The second paragraph delves into the differentiation between addiction and compulsion, emphasizing the importance of this distinction for clinical treatment. It explains that while addiction involves repeated use of positive reinforcers leading to negative consequences, compulsions are behaviors repeated to escape negative feelings, such as in OCD. The paragraph uses the example of hand washing in OCD to illustrate compulsive behavior, which, despite negative repercussions, is not driven by positive reinforcement and thus is not classified as addiction. The importance of understanding the difference between positive and negative reinforcers is stressed, as this understanding is crucial for appropriate treatment approaches.
📈 The Impact and Treatment of Addiction
The final paragraph addresses the societal impact of addiction, noting its high prevalence and the significant costs it imposes, including medical expenses and social issues like family breakdowns and increased accidents. It points out that only a small fraction of those with addiction receive adequate treatment. The paragraph outlines the process of addiction treatment, starting with detoxification, which can vary in intensity depending on the substance, and followed by rehabilitation aimed at maintaining sobriety. Various treatment modalities are mentioned, including therapy, medication, and social support. The concept of motivational interviewing is introduced as a method to enhance a patient's motivation to engage in treatment. The paragraph concludes by emphasizing that relapses are common and should not be viewed as failures, and that social connection is often more critical to successful treatment than mere sobriety.
Mindmap
Keywords
💡Psychoactive substances
💡Intoxication
💡Withdrawal
💡Addiction
💡Substance use disorder
💡DSM-5 criteria
💡Three Reapers
💡Positive reinforcers
💡Negative repercussions
💡Compulsion
💡Detoxification
💡Rehabilitation
Highlights
Over 90% of people in the United States use psychoactive substances regularly.
Intoxication, withdrawal, and addiction are three distinct but closely related conditions associated with substance use.
Addiction is a chronic condition marked by repeated use despite negative consequences, known as substance use disorder.
The DSM-5 lists 11 criteria for diagnosing substance use disorders, remembered by the phrase 'time to cut down, pal'.
Two or more of the DSM-5 criteria are required for a diagnosis of substance use disorder.
The 'three reapers' model simplifies addiction diagnosis: repeated use, positive reinforcers, and negative repercussions.
Repeated use of positive reinforcers without negative repercussions does not constitute addiction.
One-time use of substances with negative repercussions is not classified as addiction.
Repeated use of non-positively reinforcing behaviors, despite negative consequences, is indicative of compulsion, not addiction.
Treatment for addiction differs from that for compulsions due to their distinct clinical nature.
The mnemonic 'TRAPPED' aids in gathering a comprehensive substance history for clinical diagnosis.
The acronym 'THIS GUY' helps remember the major classes of substances that can lead to addiction.
Addiction is prevalent, with a lifetime prevalence of around 10% in the United States.
Addiction often begins in adolescence or early adulthood and can continue into older age.
Men are treated for addictive disorders more frequently than women, possibly due to differences in substance use patterns.
Addiction frequently co-occurs with other mental disorders, complicating prognosis and treatment.
The prognosis for addiction varies widely, with the addictiveness of the substance being a significant factor.
Addiction is a leading cause of death and societal costs, including medical expenses and social issues.
Less than 20% of those struggling with addiction seek treatment, highlighting the need for motivational interviewing.
Relapses are common in addiction treatment and should not be viewed as failures but as part of the recovery process.
Social support is a critical factor in successful addiction treatment, emphasizing the importance of community.
Transcripts
who uses drugs just about everybody use
of psychoactive substances is incredibly
common with over 90 of people in the
united states taking at least one on a
regular basis
while many people are able to use
psychoactive substances without negative
effects on their health a significant
minority of people will develop problems
as a result of substance use
people can experience problems related
to substances in three ways intoxication
withdrawal and addiction
these three things are closely related
but they're ultimately separate
conditions so it's important to get them
straight from the get-go
intoxication is an acute state of being
under the influence of a psychoactive
substance with the specific mix of signs
and symptoms associated with each
substance being known as its toxodrome
withdrawal is also an acute state but
this time it involves the physiological
and psychological effects of suddenly
stopping a substance which are often the
opposite of what you would see in a
state of intoxication from that same
substance
in contrast to intoxication withdrawal
addiction is a chronic condition
characterized by repeatedly using a
specific substance or engaging in a
behavior despite suffering negative
consequences as a result
when this involves drugs it is known as
a substance use disorder
it's worth pointing out that while
intoxication and addiction are closely
related concepts with addiction
typically involving repeated episodes of
intoxication from a diagnostic
perspective they should be considered
separate diagnoses as not everyone who
is intoxicated with a particular
substance is necessarily addicted to it
and not everyone who has an addiction is
currently intoxicated
the dsm-5 lists 11 distinct criteria for
substance use disorders and other forms
of addiction which you can remember
using the phrase time to cut down pal
the two will remind you that two or more
of these criteria are required for
diagnosis
the rest of the phrase will remind you
that patients spend a lot of time using
or obtaining the substance experience
cravings or urges to continue using are
unable to cut down on using the
substance even after repeated attempts
experience tolerance to the effects of
the substance so that they need more and
more to get the same effect
can have dangerous results of use
affect other people through their use
resulting in interpersonal and social
problems
experience withdrawal when they stop
using the substance end up neglecting
major roles and responsibilities such as
work or family
have physical or psychological problems
that have been created or made worse by
substance use
have given up activities like
socializing our hobbies due to excessive
use and finally have used larger amounts
of the substance or for longer than they
initially wanted
however these 11 criteria are a lot to
remember and you can recognize the
overall pattern of addiction using just
three things
we'll refer to these as the three
reapers
repeated use of positive reinforcers
despite negative repercussions
if those words describe the pattern of
someone's behavior then you can diagnose
addiction let's go ahead and look at
each of the three reapers more closely
the first is repeated use
addiction naturally involves doing
something repeatedly
this can involve use of substances which
we've talked about or it can involve
specific items or behaviors such as
gambling and slot machines
next is positive reinforcers
the specific substances and behaviors in
addiction must be positively reinforcing
as a reminder from general psychology a
positive reinforcer is something that is
given which increases the frequency of
your behavior often by giving a sense of
pleasure for example giving a child a
piece of candy for getting a good grade
is using the candy as a positive
reinforcer
finally we have the negative
repercussions
these consequences of use such as losing
a job alienating family and friends
getting into legal trouble or
jeopardizing one's health are a key part
of the equation for addiction and
addiction cannot be diagnosed in its
absence
none of these components on their own
are sufficient to diagnose addiction
even any two of them combined is not
enough it's only when all three
components combine that the specific
state of a diction emerges
let's see what happens when we remove
any one of these components from the
equation
first is repeated use of positive
reinforcers but no negative
repercussions
repeatedly using positive reinforcers is
not a problem as long as there are no
repercussions from it
technically speaking things like eating
an apple a day could fall under the
banner of repeated use of positive
reinforcers but because they caused no
negative consequences they would not
meet any reasonable definition of
addiction
next is use of positive reinforcers with
negative percussions but without
repeated use
this is slightly more problematic as
even a one-time exposure to specific
substances can cause damage
however if it's not repeated then by
definition it cannot be an addiction
for example someone who tries heroin
once could potentially end up in the
hospital if they overdose but if they
learn from the experience and never go
new heroin again it would not make sense
to call this an addiction
finally repeated use of things that are
not positively reinforcing despite
negative consequences is the thing
that's probably most tempting to call an
addiction
but it's more accurately characterized
as a compulsion
we talk more about compulsions in the
video on ocd but briefly a compulsion is
when someone does a behavior repeatedly
to get away from a negative feeling
rather than try to get a positive
feeling
for example someone with a fear of germs
may wash their hands repeatedly if they
have ocd they may do so so much that
they spend eight hours a day on this
activity
they may even suffer consequences as a
result like an inability to work or
physical injuries to their hands from
rubbing the skin raw
however because the behavior is
negatively reinforcing that is they are
washing their hands because this takes
away a feeling of distress and anxiety
rather than because hand washing gives
them a feeling of pleasure it's not an
addiction it's a compulsion
while differentiating between compulsive
and addictive behavior may seem like
just semantics from a clinical
standpoint addictions and compulsions
require very different approaches to
treatment
this makes such a distinction crucial so
make sure you understand the difference
between addictions and compulsions as
well as positive reinforcers versus
negative reinforcers before moving on
let's introduce a few tools that you can
use in clinical practice to help
diagnose addiction
first you can gather a complete
substance history using the mnemonic
trapped which stands for treatment
history route of administration amount
used pattern of use prior abstinence
effects of use both positive and
negative and duration of use
next it can be helpful to have a list of
all the major substances that can lead
to addiction let's use the mnemonic here
as well
picture someone who is suffering from an
uncontrolled addiction
his friends stage an intervention to get
him into rehab
however they realize that now there is
no one to take care of his dog the
friends look at each other with nobody
quite yet willing to step up and
volunteer to care for the dog
the question on everyone's mind
naturally is this guy's having trouble
but can his dog behave this phrase can
remind you of the major classes of
addictions to remember cannabis alcohol
nicotine hallucinogens inhalants
stimulants depressants opioids gambling
and other behavioral addictions
now that we know how to recognize and
diagnose addiction in clinical settings
let's look at the data behind this
disorder including who gets it what
happens once they get it and what forms
of treatment are effective
more than any of the conditions we've
talked about in other videos so far
addiction is a highly variable disorder
that is dependent upon multiple factors
most important among these is the
specific substance involved as tobacco
use disorder differs from alcohol use
disorder which differs from opioid use
disorder and so on
nevertheless despite this wide variation
a few consistent themes do emerge when
looking at addiction across the lifespan
taken as a whole addiction is one of the
most common psychiatric conditions with
a lifetime prevalence of around 10
percent of people in the united states
this gives it a relatively high base
rate in the population making it prone
to under diagnosis rather than over
diagnosis
the risk of under diagnosis is
compounded further by the fact that many
people will attempt to minimize or hide
addictive behaviors from their
healthcare providers due to the stigma
and prejudice that often occur
most addictions begin during adolescence
or early adulthood with some arguing
that substance use is in many cases a
pediatric disease
however in other cases addictive
behavior can continue on into adulthood
or older age as well
in systematic studies men and women
appear to be equally vulnerable to
addiction
however in clinical settings men are
treated for addictive disorders more
than twice as often as women
this difference in gender ratio is
likely due to the fact that men tend to
use illegal substances more often than
women who may be more prone to
addictions involving legal substances
such as alcohol or benzodiazepines that
are less likely to come to legal or
clinical attention even if they can be
just as harmful
addiction is frequently comorbid with
other mental disorders in fact up to
half of all people with a mental
disorder will meet lifetime criteria for
a substance use disorder and vice versa
the presence of both an addiction and a
mental disorder known as dual diagnosis
worsens the prognosis for both types of
disorders considerably
this makes screening for addictive
behaviors important for every patient
presenting with mental health concerns
like other aspects of addiction the
prognosis for addictive behaviors is
highly variable with the strongest
predictor of prognosis being the
specific substance involved
substances differ significantly in
regard to how addictive they are with
some being incredibly addictive and
others having only minimal addictive
potential
for example less than 10 percent of
people who try cannabis become dependent
on it but this increases to 15 for
cocaine 25 for heroin and more than 65
for nicotine
the inherent addictiveness of the
substance also plays a large role in how
easy it is to quit with cannabis use
disorder taking on average five years to
enter remission while tobacco's disorder
can take up to 25 years
taken as a whole addiction is one of the
largest problems facing society today
and it's estimated that up to 20 of all
deaths in the united states are related
to disorder in some form
addiction exacts further costs on
society in terms of high medical costs
broken families and increased rates of
accidents overdoses suicide and violence
despite these costs barely over 10
percent of people struggling with
addiction receive high quality treatment
like its prognosis treatment for
addiction is also highly variable
for some people quitting an addiction is
as simple as deciding to stop
for others the initial desire to quit is
followed by decades of bouncing between
abstinence and relapses
for still others the desire to quit is
never there at all
because of this variability statistics
on the efficacy of addiction treatment
are not very informative until they are
broken down by the specific substances
involved
as a general process treatment of
addiction involves facilitating the
initial transition to achieving sobriety
known as detoxification or detox
some substances don't have a dangerous
withdrawal state so detox is as easy as
just stopping for other substances like
alcohol however detoxification may
require admission to a medical facility
for intensive monitoring to avoid the
potentially harmful or even
life-threatening effects of withdrawal
detoxification is followed by treatment
focused on maintaining sobriety which is
known as rehabilitation or rehab
rehabilitation can be accomplished using
a variety of treatment modalities
individual and group therapy can teach
skills to decrease cravings and
impulsivity for certain substances such
as alcohol and opioids medications can
play a positive role by preventing
withdrawal reducing cravings and
blocking the positive effects of the
drug
however for other substances like
methamphetamine or cocaine no
medications have yet proven to be
helpful
of course even beginning the process of
detoxification and rehabilitation
requires that the patient is motivated
for treatment
however in many cases addiction can
significantly impair one's insight that
their use is problematic even in the
face of evidence to the contrary
in fact it's estimated that less than 20
percent of people struggling with
addiction will seek treatment on their
own
to address this a specific counseling
technique known as motivational
interviewing can be used to increase a
patient's motivation to treat their
addiction
rather than approaching all patients
with addiction in the same way
motivational interviewing encourages
providers to identify the stage of
change that the patient is in and use
specific techniques that are appropriate
for that stage
by matching interventions to the stage
of change patients are more likely to
quit
motivational interviewing is very
effective with large effects compared to
treatment as usual
relapses are common in addiction
treatment and relapses should not be
seen as failure either on the part of
the patient the provider or the
treatment itself
in fact placing too strong of an
emphasis on sobriety as the only
endpoint of treatment can sometimes be
counterproductive
instead of merely eliminating the
addiction it's more helpful to replace
it with other activities that the
patient finds satisfying
for many people engaging in meaningful
work hobbies or social activities can
help to prevent the sense of boredom or
emptiness that often leads to relapses
some evidence suggests that social
support is one of the most important if
not the most important predictor of
successful treatment
because of this it's helpful to think
that the opposite of addiction is not
sobriety but connection in community
thanks for watching there's more to say
about addiction than just that but this
video should help to serve as a jumping
off point for learning about the
different substances and behaviors that
can turn into an addiction
if you're interested in learning more i
have a playlist on youtube with videos
covering recreational substances in more
detail
you can also order my books memorable
psychopharmacology and memorable
psychiatry on amazon
links to both books are in the
description below thanks again for
watching bye for now
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