Addiction and Substance Use Disorder Mnemonics (Memorable Psychiatry Lecture)

Summary

The 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

00:00

🌟 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.

05:00

🔍 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.

10:02

📈 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.

Keywords

💡Psychoactive substances

Psychoactive substances are chemicals that affect the central nervous system and can alter perception, mood, consciousness, or behavior. In the video, it is mentioned that over 90% of people in the United States take at least one psychoactive substance regularly, highlighting their prevalence and potential impact on society.

💡Intoxication

Intoxication refers to the acute state of being under the influence of a psychoactive substance. The script explains that each substance has a specific mix of signs and symptoms known as its toxodrome, which is crucial for understanding the immediate effects of substance use.

💡Withdrawal

Withdrawal is the physiological and psychological state that occurs when a person suddenly stops using a substance. It is often characterized by effects opposite to those of intoxication, as described in the video, and can be a significant barrier to overcoming addiction.

💡Addiction

Addiction is defined in the video as a chronic condition where a person repeatedly uses a substance or engages in a behavior despite negative consequences. It contrasts with intoxication and withdrawal as it is not an acute state but a long-term pattern of behavior, often leading to substance use disorder.

💡Substance use disorder

Substance use disorder, as mentioned in the script, is a formal diagnosis for addiction when it involves drugs. The video emphasizes the importance of distinguishing between intoxication and addiction, as not everyone who is intoxicated is addicted, and vice versa.

💡DSM-5 criteria

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides 11 criteria for diagnosing substance use disorders. The video uses the mnemonic 'time to cut down pal' to help remember these criteria, which are essential for clinical diagnosis and understanding the severity of addiction.

💡Three Reapers

The 'Three Reapers' is a concept introduced in the video to simplify the diagnosis of addiction. It includes repeated use, positive reinforcers, and negative repercussions. These three elements, when combined, characterize addictive behavior, as explained by the video's discussion on the patterns of addiction.

💡Positive reinforcers

Positive reinforcers are substances or behaviors that increase the frequency of a particular action by providing pleasure or satisfaction. The video explains that for a behavior to be considered addictive, it must involve positive reinforcement, such as the pleasure derived from drug use.

💡Negative repercussions

Negative repercussions are the harmful consequences that result from addictive behaviors, such as job loss or health problems. The video stresses that these consequences are a key part of diagnosing addiction, as addiction involves continued use despite these negative outcomes.

💡Compulsion

A compulsion is a repeated behavior aimed at reducing negative feelings rather than obtaining pleasure, as explained in the video. It contrasts with addiction, as compulsions are not driven by positive reinforcement but by the desire to alleviate distress, such as hand-washing in OCD.

💡Detoxification

Detoxification, or detox, is the process of facilitating the initial transition to sobriety, which may involve medical supervision to manage withdrawal symptoms, as discussed in the video. It is a critical first step in treating addiction for many substances.

💡Rehabilitation

Rehabilitation, or rehab, is the phase following detox where treatment focuses on maintaining sobriety. The video describes various modalities, including therapy and medication, that can be used to support individuals in their recovery from addiction.

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