精神活性物质所致精神障碍英文课件

PsychoactiveSubstanceRelatedDisordersWeiHao,MD.,Ph.D.Terminology

substance,drugaddictiondependenceabusetolerancewithdrawalsyndromeSubstances

Substanceisagroupofchemicalsthatcanalterhumanmindandbehaviors.Theword“substance”isgenerallypreferabletotheword“drug”.InDSM-III-Rsystem,“drug”isalsocalled“psychoactivesubstances”,buttheDSM-IVreferstothemsimplyas“substance”.

Illicitdrugsaredefinedasagroupofsubstancescontrolledbyinternationalandnationallaws,usedfornon-medicalpurpose,includingopiate,cocaine,amphetaminetypestimulants(ATSs),cannabis,hallucinogens,etc.Addiction

Thetermaddictiondescribesabraindisorder,withprogressive,chronic,relapsingcharacteristicsthatgenerallyinvolvesthecompulsion,lossofcontrol,andcontinuedusesubstance,despiteadverseconsequences.Dependence

Basically,twoconceptshavebeeninvokedregardingthedefinitionofdependence:Psychologicaldependence:craving,compulsivelysubstance-seekingactivitiesandrelatedevidenceofpathologicalusepatterns.Physicaldependence:toleranceorwithdrawal.ToleranceAfterrepeatedexposuretodrug,individualsrequirealargerdosetoproduceintoxicationofthemagnitudethatwasexperiencedwhenthedrugwasfirstadministered.Aneedformarkedlyincreasedamountsofthesubstancestoachieveintoxicationordesiredeffect;Markedlydiminishedeffectwithcontinueduseofthesameamountofthesubstance.WithdrawalSyndromeAsubstance-specificsyndromeoccurredupondiscontinuationorreductionofchronicadministrationofanysubstance(oradministrationofaspecificantagonist);Thesyndromeischaracterizedbyaspectrumofsignsandsymptomsthataregenerallyoppositetothoseofpharmacologicaleffects;Thesubstance-specificsyndromecausesclinicallysignificantdistressorimpairmentinsocial,occupational,orotherimportantareasoffunctioning.AbuseAmaladaptivepatternofsubstanceuseleadingtosignificantadverseconsequences,suchasimpairmentordistress.Theremayberepeatedfailuretofulfillmajorroleobligations,repeateduseinsituationsinwhichitisphysicallyhazardous,multiplelegalproblems,andrecurrentsocialandinterpersonalproblemsMajorClassesofSubstancesClassCommonexamplesAlcoholBeer,wine,whiskey,vodka,gin,spiritsAmphetaminetypestimulants(ATSs)Amphetamine,methamphetamine,dietpills,ecstasyCaffeineCoffee,tea,CocaineCocaleavesorpaste,cocainealkaloid(crack)CannabisMarijuana,hashish,THCHallucinogensLSD,mescalineNicotineCigarettes,cigarOpiatesHeroin,morphine,codeine,buprenorphine,methadoneSedatives,hypnotics,andanxiolyticsBenzodiazepines,barbituratesDriedopiumpoppyOpiumHeroinAmphetamine,Methamphetamine(ice),MDMA（Ecstasy),MDA(Ecstasy)EcstasyMarijuanaCrackCocaineKetamineDrugAbuseStatusinChinaCigaretteAlcoholIllicitDrugSmokinginChinaChinaisnumberonecigaretteproducer,theoutputofcigaretteaccountfor1/3intheworld,is3timeslargerthaninUS;Approximately10%ofrevenuecomefromtobaccoindustriesinChina;ThesmokingratesinChinaare60%~70%formalesand7%~15%forfemales,thereare1.1billionsmokersintheworld,3200millioninChina;ThecontentofnicotineandtarincigaretteinChinaismuchhigherthanindevelopedcountries;Thereare2millionpeopleinChinadiedfromsmokingrelateddiseaseseachyear.TheRevenuefromTobaccoIndustriesinChina(YMBBillion)

TheAmountofCigaretteProducedandSoldinChina(Billion)DrinkinginChinaThepercapitaconsumption(15yearoldandover)isabout4litersinpurealcohol;TheoutputofalcoholbeveragesinChinaincreases10%eachyear;Thedrinkingrelatedpsychologicalandphysicaldiseasesincreasesteadilyinrecent15years.Nationalepidemiologicalsurvey(1994)Themale,femaleandtotaldrinkingrateswere84.1%,29.3%and59.5%,respectivelyMorethanhalfofmaledrinkersand90.0%offemaledrinkersusedalcoholonceaweekorless.Morethan16.1%ofmaledrinkersand2.5%offemaledrinkersdrankonceadayormore.Theannualconsumptionofpurealcoholforeachrespondentwas3.60liters;Malesconsumed18.6timesmorealcoholthanfemalesTheNumberofRecordedIllicitDrugUsersinChina(in10000)Thenumberofcases

ofinitialuseinthedifferentyearsLife-timePrevalenceRatesofDrugUsein1993and1996%TheSubstancesEverUsedinDrugUser’sLife%Life-timeandcurrentdruguseinUSHNcracksdownondrugabuseTheAIDS,DrugandProstituteCommitteeannouncepolicewouldstakeoutcornersacrossthecityfromOct.1toNov15topickupaddictsanddealers;Anyonecaughtusingdrugswouldgotorehabilitationcenters;Asurveydonebycommitteesuggested12,555drugaddictlivedinHanoi,morethan5,800wereinrehabilitationcenterinthepast;Moreresearchonthenumberofdrugaddictsandtherelapseratewillbeconducted.VietnamNews,Oct3,2003NAChairmanpraisesHCMcity’santidrugeffortNationalAssemblyChairmanNguyenVanAnsaidthefightagainstsocialproblemssuchasdruguseshouldbesteppedupconstantly;Localadministratorsreportedthein2001,District6had32hot-spotsofdrugsellerandusers,withnearly1400drugaddicts;Morethan1100newusers,including360repeatoffenderhavebeendiscoveredsincelastJuly;EffectiveeducationtopeopleinthefightagainstsocialvicesalongwithcriminalcontrolhasbeenconductedThenumberofdrugusecasesintheareahasdroppedsharply,thenumberofaddictshasdecreasedby2500witha99.6%ofallcaseslistedforsupervisionbylocalauthorities;Ofthedistrict’s14wards,localofficialsreportthat11nowdonothavehot-spotsofnarcoticsellersandusers,whilemostoftheusershavebeenputinschoolswheretheyaretreatedintheprocessofrecoveringfromaddiction.SUBSTANCEUSERELATEDREASONS

PharmacologicalReasonSocioculturalReasonPsychologicalReasonNeurochemicalReasonPharmacologicalReason

Anysubstancedohavepharmacologicalproperties,thatcanchangehuman’semotion,consciousnessandbehaviorsisaddictive.

TheoreticalcontinuumStrongaddictiveCompulsivecravingPhysicaldependenceLegalcontrolHighvulnerabilityHeroinLessaddictiveHabituationNon-physicaldependenceSociallyacceptedLessvulnerabilityCaffeineSocioculturalReason

Religion:differentsocialculturalhasdifferentideatodrugabuse;Gender:societyismoretolerabletomalesubstanceusethanfemales;Economicstatus:alcoholconsumptionlevelstendtoincreasewiththeincreasingofsocioeconomicstatus;Area:illicitdrugusemorefrequentlyseeninurbanorsuburbanareas;Availability:supplyincreasedemand.PsychologicalReason

PersonalitycharacteristicsCuriousImpulsiveRebellionAntisocialattitudeandbehaviorPsychologicalrewardsPositiveenforcementNegativeenforcementNeurochemicalReason

Humans,aswellasotherorganismsengageinbehaviorsthatarerewarding.Therearenaturalrewardsaswellasartificialrewards,suchasdrugs.Therewardpathwayistegmentalarea(VTA),thenucleusaccumbens(Nas)andtheprefrontalcortex.Fig.1.Atypicaltwo-compartmentCPPapparatus.DIAGNOSIS

Thesubstanceuserelateddisorderscanbeclassifiedas:SubstanceinducedorganicmentaldisordersandSubstanceusedisorder

DependenceAbuseSubstanceinducedorganicmentaldisorders

IntoxicationWithdrawalDeliriumWithdrawaldeliriumDelusionaldisorderMooddisorderAlcohol++

+

+

+ATSs+++

+

Cannabis+

+

Cocaine+++

++Hallucinogen+

++Opioid++

CNSdepressants++

+

+DiagnosticCriteriaforSubstanceDependence(1)Amaladaptivepatternofsubstanceuse,leadingtoclinicallysignificantimpairmentordistress,asmanifestedbythree(ormore)ofthefollowing:1.Tolerance2.Withdrawal3.Thesubstanceisoftentakeninlargeramountoroveralongerperiodthanwasintended4.ThereisapersistentdesireorunsuccessfuleffortstocutdownorcontrolsubstanceuseDiagnosticCriteriaforSubstanceDependence(2)

5.Agreatdealoftimeisspentinactivitiesnecessarytoobtainthesubstance6.Importantsocial,occupational,orrecreationalactivitiesaregivenuporreducedbecauseofsubstanceuse7.ThesubstanceuseiscontinueddespiteknowledgeofhavingapersistentorrecurrentphysicalorpsychologicalproblemthatislikelytohavebeencausedorexacerbatedbythesubstanceDiagnosticCriteriaforSubstanceAbuse

Amaladaptivepatternofsubstanceuseleadingtoclinicallysignificantimpairmentordistress,asmanifestedbyone(ormore)ofthefollowing:recurrentsubstanceuseresultinginafailuretofulfillmajorroleobligationsatwork,school,orhomerecurrentsubstanceuseinsituationinwhichitisphysicallyhazardousrecurrentsubstance-relatedlegalproblemscontinuedsubstanceusedespitehavingpersistentorrecurrentsocialorinterpersonalproblemscausedorexacerbatedbytheeffectofthesubstanceTREATEMNTPRINCIPLESGoalsofTreatmentAssessmentPsychiatricManagementPharmacologicalTreatmentsPsychosocialTreatmentsGoalsofTreatment

AbstinenceorReductioninSubstanceUseReductionintheFrequencyandSeverityofRelapseImprovementinPsychologicalandSocial/adaptiveFunctioningAssessment(1)Asystematicinquiry:Thedegreeofintoxication;Theseverityofwithdrawal;Mostrecentdoseandtimeelapsesincemostrecentuse;themodeofonset,quantity,frequency,anddurationofuse;Subjecteffectsofallsubstanceused.Acomprehensivegeneralmedicalandpsychiatrichistory:Acompletephysicalandmentalstatusexamination,toascertainthepresenceorabsenceofcomorbidgeneralmedicalorpsychiatricdisorder,aswellassignsandsymptomsofintoxicationorwithdrawal.Assessment(2)

Ahistoryofanypriortreatmentforsubstanceusedisorders:Acompletefamily,social,andsubstanceusehistory:Bloodandurinescreeningfordrugsofabuseandlabtestsforabnormalitiesthatmayaccompanyacuteorchronicsubstanceuse.Screeningforinfectiousandotherdisease.PsychiatricManagementEstablishingandMaintainingaTherapeuticAllianceMonitoringthePatient’sClinicalStatusManagingIntoxicationandWithdrawalStatesReducingtheMorbidityandConsequencesofSubstanceUseDisordersFacilitatingAdherencetoaTreatmentPlanandPreventingRelapseProvidingEducationaboutSubstanceUseDisorderandTheirTreatmentEstablishingandMaintainingaTherapeuticAllianceAnessentialfeatureofpsychiatricmanagementofpatientswithsubstanceusedisordersistheestablishmentandmaintenanceofatherapeuticalliance:Obtainsnecessarydiagnosticandtreatment-relatedinformation,Gainstheconfidenceofpatientandsignificantothers,andBeavailableintimesofcrisis.Withinthecontextofthisalliance,learning,practicing,andinternalizingchangesinattitudesandbehaviorhelpfultorelapseprevention.MonitoringthePatient’sClinicalStatusTheongoingevaluationofthepatient’ssafetyiscritical,becausethepatient’sclinicalstatusmaychangeovertime.Patient’ssuicidalorhomicidalthoughtandpossibleaggressivebehaviorSideeffectsIfpatientsisreceivedtheappropriatetreatmentandpatient’sresponsetotreatmentDetectionofrelapse(labmonitoringthroughbreath,blood,saliva,andurinetestingfordrugofabused)ManagingIntoxicationStateIngeneral,acutelyintoxicatedpatientsrequiremaintenanceinasafeandmonitoredenvironment,witheffortstodecreaseexternalstimulation.

Clinicalassessmentisdirectedtowardascertainingwhichsubstancehavebeenused,therouteofadministration,dose,timesincethelastdose.FacilitatingAdherencetoaTreatmentPlanandPreventingRelapse

AddressthebarriersEncouragingthepatientsparticipateinself-helporprofessionallyledgroupsEncouragingthedevelopmentofasubstance-freepeergroupandlifestyleHelpingthepatientdeveloptechniquestoimproveinterpersonalrelationshipinfamily,work,andsocialsettingsEncouragingthepatienttoseeknewexperiencesandrolesconsistentwithasubstance-freeexistence(e.g.,greaterinvolvementinvocational,social,andreligiousactivities)Helpingpatientsanticipateandavoiddrug-relatedcueProvidingtreatmentofcomorbidpsychiatricandgeneralmedicalconditionsTrainingpatientsinself-monitoringaffectiveorcognitivestatesassociatedwithincreasedcravingandsubstanceuseProvidingcopingandsocialskillstrainingtohelppatientsbecomeinvolvingsatisfyingdrug-freealternativeactivities.PharmacologicalTreatments

MedicationstoTreatWithdrawalStatesMedicationstoDecreasetheReinforcingEffectsofAbusedSubstanceMedicationsthatDiscouragetheUseofSubstanceMedicationstoTreatWithdrawalStatesSubstitutetherapyReplacingtheabuseddrugwithadruginthesamegeneralclassbutwithalongerdurationofactionandthenslowlytaperingthelonger-actingdruginawaythatallowstimefortherestorationofphysiologichomeostasis.Examplesincludetheuseofmethadoneinthetreatmentofheroinwithdrawalandbenzodiazepinesinthetreatmentofalcoholwithdrawal.Non-substitutetherapySymptomatictreatmentHerbalmedicineAcupunctureMedicationstoDecreasetheReinforcingEffectsofAbusedSubstance

Avarietyofmedicationhasbeenusedtoblockthephysiologicand/orsubjectivereinforcingeffectsofabusedsubstance.Forexample,theμreceptorantagonist,naltrexoneblocksthesubjectiveandphysiologiceffectofsubsequentlyadministeredopiatedrugs.MedicationsthatDiscouragetheUseofSubstance

Themostprominentexamplewithinthiscategoryisdisulfiram(Antabus),adrugthatinhibitstheactivityofaldehydedehydrogenase,theenzymethatmetabolizeacetaldehyde,thefirstmetabolicbreakdownproductofalcohol.Inthepresenceofdisulfirampretreatment,alcoholuseresultsintheaccumulationoftoxiclevelsofacetaldehyde,accompaniedbyahostofunpleasant. ADHethanol----acetaldehyde-------aceticacidPsychosocialTreatments

Themajorpsychotherapyinclude:cognitivetherapybehavioraltherapyinterpersonaltherapy.Psychosocialinterventionscanbeuseful:tochange:copyingstyleemotionexpressionbehaviorstylecognitiontoimprovetheirpersonalrelationship.Treatmenteffectsmaynotbeapparentuntilthepatienthasbeenconsistentlyintreatmentfor3monthsormore.TheFactorsRelatedtotheTreatmentOutcomesThenumberandtypeofsubstanceused;Theseverityofthedisorderandthedegreeofassociatedfunctionalimpairment;Theassociatedgeneralmedicalandpsychiatricconditions;Thepatient’sstrengths(protective/resiliencyfactors)andvulnerabilities,andThesocial/environmentalcontextinwhichtheindividuallivesandwillbetreated.SomeMisunderstandingtowardsDrugAbuseDrugdependenceissimplyafailureofwillorofstrengthofcharacterDependenceisabraindisorderandpeoplewithdrugdependencehavealteredbrainstructureandfunction.Itistruethatdependenceisexpressedintheformofcompulsivebehavior,butthisbehaviorisstronglyrelatedtobrainchangesoccurringovertime,withrepeateduseofdrugs.Inrecentyearsgeneticswasfoundtobeassociatedwiththepredispositionofindividualstobemoreorlesssusceptibletodevelopdrugdependence.PeoplewhohavedrugdependencecaneasilymovebacktonormalDrugdependenceisdifficulttocontrolduetocompulsivedruguseandcraving,leadingtodrugseekingandrepetitiveuse,eveninthefaceofnegativehealtha