Substance use disorder
(The psychiatry bible)
Substance use disorder
This term encompasses both dependence on and abuse of drugs usually taken voluntarily for the purpose of their effect on the central nervous system (usually referred to as intoxication or “high”) or to prevent or reduce withdrawal symptoms. These mental disorders form a subcategory of the substance-related disorders.
Associated with these drugs: alcohol, amphetamine-like, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, hypnotics.
Also: drug abuse, substance dependence, alcoholism, addiction, SUD
Sensible Psychology Definition
The DSM seems to like breaking things down to the point where what is really only one psychological difficulty is seen as many different problems.
There may be some point in distinguishing between behavioural addiction (such as so-called ‘sex addiction’ or ‘exercise addiction’ or gambling) and substance addiction.
But – as far as psychologists can tell – addiction, whatever it gets attached to, works in the same way, on a continuum from mild to severe. The negative consequences for the addicted (or ‘dependent’) person can be extremely severe when toxic substances are the focus because of the potentially terrible physical side effects of frequent uncontrolled use of substances like alcohol, nicotine or cocaine.
Substance use disorder: the myth of physical addiction
Many people who feel caught in the grasp of a ‘substance use disorder’ feel they are helpless to change anything. This may be partly due to the way addiction has been viewed by professionals and lay people alike.
There is no ‘gene for addiction’. It’s a damaging cliché to speak of having an ‘addictive personality’ but many people do see themselves in this rather damning light. In fact, however, all human beings have the capacity to do things over and over rather compulsively, from earning money to gathering food and learning new things. We all need to be able to apply our ‘addictive personality’ when we want to improve as human beings or even just ensure our physical survival.
- a ‘disease’ with a simple cause (perhaps genetic) rather than a behaviour that lies within a social and emotional context. Now, there may be some genetic element (such as a natural predisposition to sensation seeking), but in the main attempting to link substance dependency risk to biology is a bit of a blind alley.
- a permanent condition, part of the ongoing nature of who you are, have always been and always will be. “You are your addiction” or “Once an alcoholic, always an alcoholic!” – even if you haven’t drunk for many years. (Presumably, then, there were ‘alcoholics’ walking around in the couple of million years of human history before we started on the booze. They just didn’t know it!)
But how much of this ‘received wisdom’ or ‘professional folklore’ is actually true?
A story of baffling heroin addicts
Some (in fact, many) US military personnel fighting in Vietnam in the early 1970s took and became addicted to narcotics such as heroin (perhaps to help them face the hell of war).
The US authorities were worried that when these thousands of drug-addicted young men returned, they would continue to be addicted back home in the USA, with all the attendant social consequences. Epidemiologists were hired to make a long term study of the war veterans. What they found turned thinking about substance dependency on its head. They discovered, to their amazement, that the vast majority of the formerly addicted soldiers simply stopped taking any narcotic when they returned to normal life. They experienced no significant withdrawal problems and showed no further interest in drug use. (1)
Once the context changed and they were back living their ordinary lives again amongst family and friends the substance abuse stopped.
So much for: “Once an addict, always an addict.”
Is physical addiction real?
The ‘reward pathways’ in the brain (the dopamine receptors) certainly can come to expect nicotine or caffeine or cocaine (or even sugar), and when that expectation is thwarted, feelings of frustration, agitation and even panic may be experienced. However, (as evidenced by the war veterans mentioned above) behavioural psychological association plays a much bigger part.
When your friends stop smoking, you are more likely to stop. When you go on a long haul flight or into a cinema theatre (places where you don’t usually smoke), you are less likely to feel the pull of the evil weed, not because your physical nature has suddenly changed but because the contextual cues or ‘triggers’ which are such a big part of addiction have changed or disappeared.
It’s amazing how people can stop abusing a particular substance (with sometimes very few withdrawal effects) when old associative triggers simply change and they stop seeing the people they used to be with when taking that substance, or go to different places. (2)
What is physical and what is psychological? Or is addiction a bit of both?
Imagine you clicked your fingers a thousand times a day, for twenty years. Every time you sat down for coffee you clicked your fingers, every time you’d had sex, every time you saw certain people, every time you had a beer or a glass of wine.
Pretty soon it would start to feel as if there was a natural association between these day to day activities and clicking your fingers. Your brain would come to expect a click during these times. Going ‘cold turkey’ and not clicking might feel like ‘physical withdrawal’ as your fingers ‘wanted’ to click and you became a little agitated for a while because you couldn’t click.
Professionals might talk about finding a gene for click addiction and tell you that clickers would ‘always be clickers’ even if they stopped. Treatment drugs (with side effects) would almost certainly be prescribed and the unfortunate clickers would be described as having ‘a disease’.
The brain learns through association. You see a musical note on paper and associate it with what your fingers do on the piano or guitar. A link is formed. Addiction ‘hijacks’ the associative learning pathway that the brain relies on.
A joke too far?
All this talk of clicking fingers might seem absurd. And, of course, it wouldn’t be the same as consuming a noxious – and perhaps mind altering – substance. But remember that when people are given a ‘placebo’ drink that they believe is alcoholic, they are much less likely to report alcohol withdrawal and much more likely to feel drunk. The same is true of placebo heroin. Because of the power of expectation, heroin addicts still respond psychologically as if it’s the real thing. (3)
It works the other way, too. There is plenty of evidence that we can suffer very real and quite severe physical symptoms when we believe we have been, for example, exposed to something we are allergic to, even if this wasn’t the case. This is known as nocebo response. (4)
So how much is psychological, and how much is really physical, even when we are dealing with genuine substance dependence?
Substance abuse and your primal human needs
We’ve all known people who have gone through difficult periods such as divorce or job loss or illness, and during that time drank or smoked a little (or a lot) more than is normal for them, or who have started taking too many prescription drugs or even turned to other non-prescribed drugs. We sometimes try to ‘self medicate’ to escape from unhappiness or to tranquilize pain and anxiety. The trouble is that, ultimately, the attempted solution of self medication chronically adds to rather than relieves life’s problems.
If people are lonely, disconnected from community, directionless in life, feeling undermined or insecure generally, in short, when their ‘primal emotional needs’ remain unfulfilled (or are no longer being properly met), then they (we) all become much more susceptible to substance misuse.
Because anything that seems to offer a break from unhappiness becomes increasingly and dangerously attractive.
The sensible psychology approach
When people’s emotional needs are unfulfilled over time, they become more susceptible to addiction. Helping someone overcome ‘substance use disorder’ includes helping them meet their human needs in healthy ways, so the substance stops feeling ‘necessary’ or, worse, as if it is some kind of ‘friend’ (which it most certainly isn’t).
Hypnosis is an effective tool to help people:
- dismantle the associative triggers that used to maintain the pattern of their addiction
- envisage and plan for a future free of the toxic substance
- focus on meeting their emotional needs in ways which are healthy and genuinely beneficial for them
- break the ‘hypnotic’ narrow focus pull of the substance abusing behaviour
- remove the addictive behaviour from their core identity, so it is not who they are but only what they had been doing – literally ‘alienating’ the substance.
There are millions of ex-alcoholics, ex-crack cocaine users and, yes, even ex-glue sniffers out there who really no longer need to be identified by what they used to do.
- See: Robins, L.N., Helzer, J.E Hesselbrock, M. and Wish, E. (1980) ‘Vietnam veterans three years after Vietnam: How our study changed our view of heroin’ published in: The Yearbook of substance use and abuse: Volume 2, Human Science Press.
- See: The Placebo Response and the Power of Unconscious Healing by Richard Kradin, Routledge (2008),
- See: Kirsch, I. (Ed.). (1999). How Expectancies Shape Experience. Washington DC,: American Psychological Association.
- In his book The Emperor’s New Drugs: Exploding the antidepressant myth (Bodley Head, 2009), Irving Kirsch describes research that showed that many people with skin allergies produced physical allergic reactions in their skin when they expected them to happen (even when in reality they had not been exposed to what they were allergic to).
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