There is no specific sympotms which identify alcoholism, it is the number of frequency of the effect which define the disorder 

How many ADVERSE effects the substance has on the person 

Maladaptive pattern (2 or more time) of substance use, leading to impairment or distress, manifest in 1 of the follding in 12-month period: 

- lover functioning due to use

-use in hazardous situations (eg driving) 

-recurrent legal problems connected to use

-use despite consquences 

Does NOT meet the criteria for dependence! 

Maladaptive pattern of substance use, leading to impairment or distress, manifest in 3+ symptoms in a 12-month period: 

-Tolerance:

increased use to maintain effect or

decreased effect if same level use maintained 

-Withdrawl: 

Characteristic withdrawal syndrome for theat substance

same or similar substance used to relieve withdrawl

use of opiates for pain have high level of tolerance/dependence but low potential for addiction 

-Loss of control: 

Substance taken in larger amouts or longer time than was intended 

-Time Spend 

Considerable effect or time in use and procurrent

-Lower LOF in social, occupational, recreaional areas

-Use despited consequences 

W/ or W/out Physiological dependence 

Course @ 1 month: 

• Early Full Remision 
• Early Partial remission 
• Sustained full remission 
• Sustained partial remission 
• On agonist therapy (methadone or buprenorphine)
• In a controled environment 

Vaillant Study

National History of Alcoholism

•There are no specific symptoms, which identify alcoholism--it is the number and frequency of alcohol-related problems, which identify the disorder

•The only way to diagnose substance abuse is by the effect of the drugs on ones life, not by the quantity or the frequency alcohol or drugs are used

•Alcoholics who achieve stable abstinence are not pre-morbidly healthier than alcoholics who continue drinking

·      This suggests alcoholism is usually not a symptom of an underlying personality disorder

•Outcome depends little on the type of treatment

·      Special inpatient alcoholism units are no more successful in outcome than community programs or AA or provision of common-sense advice

•No matter what treatment is given, 10-20% will never relapse, and 2-3% will achieve stable recovery each year

•Substance intoxication

•Substance withdrawal (specific to drug)

•Substance-induced delerium (impairment in sensorium)

•Substance-induced persisting dementia (lower cognitive functioning)

•Substance-induced persisting amnestic disorder

•Substance-induced psychotic disorder

•Substance-induced mood disorder

•Substance-induced anxiety disorder

•Substance-induced sexual dysfunction

•Substance-induced sleep disorder

•A substitute dependency

·      e.g. AA, religion, people, work, exercise, hobbies

•An external reminder that drinking is aversive

·      e.g. drunkalogs, antabuse, jail

•A source of inspiration, hope, self esteem

·      e.g. recovery stories, religion, therapy

•Unambivalently offered social support

·      e.g. friends, community

Principles of Drug Addiction Treatment: A Research-based Guide (National Institutes of Health, 1999)

1.No single treatment is appropriate for all individuals

2.Treatment needs to be readily available

3.Effective treatment attends to multiple needs of the individual, not just his or her drug use

4.An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person’s changing needs

5.Remaining in treatment for an adequate period of time is critical for treatment effectiveness (3 months, on average)

6.Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction

7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies

8.Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way

9.Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use

10.Treatment does not need to be voluntary to be effective

11.Possible drug use during treatment must be monitored continuously

12.Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection

13.Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment

Basic Forms of Substance Abuse/Dependence Treatment

Medical

•Medical detoxification

•Agonist Maintenance (methadone/LAAM)

•Antagonist Treatment (naltrexone/buprenorphine)

Behavioral

•Outpatient drug-free treatment

•Long term residential treatment (TCs)

•Short-term residential treatment -- “28 days”

•Specialized treatment for criminal justice populations

Are Methadone and Other Meds a “Substitute Addiction”?

•No!

•Euphoria à Crash à Craving cycle defines addiction and behavioral disruption

•Removal of euphoria and craving disrupts the cycle

•Methadone has a gradual onset (no euphoria), longer half life (no crash)

 Scientifically Supported Substance Abuse Treatments
(National Institutes of Health)

•Relapse Prevention

•Supportive-Expressive Psychotherapy

•Individualized Drug Counseling

•Motivational Enhancement Therapy

•Combined Behavioral and Nicotine Replacement Therapy for Nicotine Dependence Addiction

•Community Reinforcement Approach (CRA) Plus Vouchers

•Behavioral Couple Therapy for Alcohol Abuse

•Voucher-Based Reinforcement Therapy in Methadone Maintenance Treatment

•Day Treatment with Abstinence Contingencies and Vouchers

•The Matrix Model for Cocaine Addiction

DSM General Criteria

Personality Disorders

•Lifelong patterns of thinking, feeling, interpersonal relations, and impulse management which deviates markedly from the expectations of one's culture (new to DSM-IV)

•Integrated, rather than discrete behavior

• Relatively inflexible across contexts (horizontal integration)

• Longstanding, can be traced to adolescence (vertical integration)

•Leads to distress or impairment in function

•Cant be accounted for by an Axis I (symptom) disorder

DSM General Criteria

Personality Disorders

•Odd/Eccentric Cluster

·      Paranoid (SUSPICIOUS)

·      Schizoid (ASOCIAL)

·      Schizotypal (ECCENTRIC)

•Dramatic/Erratic Cluster

·      Borderline (UNSTABLE)

·      Narcissistic  (EGOISTIC

·      Histrionic  (DRAMATIC)

·      Antisocial (AGGRESSIVE)

•Anxious/Fearful Cluster

·      Avoidant (WITHDRAWN)

·      Dependent  (SUBMISSIVE)

·      Compulsive  (CONFORMING)

Paranoid Personality

•Suspicion

•Preoccupation with loyalty, trustworthiness

•Reluctant to confide in others

•Sees hidden meanings & motives

•Bears grudges

•Perceives attack on character

•Heightened attention to partner fidelity

•Neither desires nor enjoys close relationships

•Prefers solitary activities

•Little interest in sex  

•Takes pleasure in few, if any, activities

•Lacks close friends/confidants

•Indifferent to praise/criticism  

•Emotional coldness, detachment, flattened affect

•Ideas of reference

•Odd beliefs, magical thinking

•Unusual perceptions

•Odd thinking and speech

•Suspiciousness, paranoid ideas

•Inappropriate or constricted affect

•Odd, eccentric behavior or appearance  

•Lack of close friends, confidants

•Social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

•Fear of abandonment

•Unstable and intense relationships, alternating between idealization/devaluation

•Identity disturbance, unstable self image  

•Impulsive and self-damaging behavior

•Suicidal threats, actions, or self-mutilation

•Affective instability

•Chronic feelings of emptiness

•Inappropriate, intense anger  

•Transient, stress-related paranoia or dissociation

•Grandiose sense of self-importance

•Preoccupied: success, power, brilliance, beauty, love

•Belief in own uniqueness, and best be understood by other special people

•Needs excessive admiration of others

•Strong sense of entitlement

•Exploits others to achieve his or her own ends

•Lacks empathy

•Envious or believes others are envious of him or her

•Arrogant affect

•Uncomfortable in situations in which (s)he is not the center of attention

•Inappropriate sexually seductive or provocative behavior

•Rapidly shifting and shallow expression of emotions

•Uses physical appearance to draw attention to self

•Speech is excessively impressionistic and lacking in detail

•Self-dramatization, theatricality, and exaggerated expression of emotion

•Easily influenced by others or circumstances

•Considers relationships to be more intimate than they are

•Failure to conform to social norms (unlawful behavior)

•Deceitfulness, lying, use of aliases, conning for personal gain

•Impulsivity, failure to plan ahead

•Irritability and aggressiveness, frequent physical fights  

•Reckless disregard for safety of self, others

•Irresponsible, doesn’t work or pay debts  

•Lack of remorse, indifferent to hurting others

•Avoids jobs with interpersonal contact

•Unwilling to get involved with people unless certain of being liked

•Restrained relationships, fear of being shamed  

•Preoccupied with being criticized

•Inhibited in interpersonal situations because of inadequacy

•Views self as socially inept, unappealing, or inferior  

•Reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

•Difficulty making everyday decisions without advice  

•Needs others to be responsible for areas of life

•Hard to disagree with others because of fear of loss

•Difficulty initiating projects or doing things on own  

•Goes to great lengths to obtain nurturance and support

•Feels uncomfortable or helpless when alone  

•Seeks another relationship quickly when a close relationship ends

•Preoccupied with fears of being left to take care of self

•Preoccupation with details, rules, lists, order, organization, bodily functions, or schedules  

•Perfectionism to the point of immobilization

•Excessive devotion to work and productivity to the exclusion of leisure  

•Over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or values

•Inability to discard worn-out, worthless objects  

•Reluctance to delegate tasks or work with others unless they submit to exactly his or her way of doing things

•Miserly spending style, money is hoarded

•Rigidity and stubbornness