De – Addiction Treatments

Addiction/ Substance related disorders/ Substance abuse disorders etc.

Substance (drug) dependence (addiction) – the word ‘drug’ is replaced by word ‘substance’ and ‘addiction’ is replaced by word ‘dependence’ in all scientific definitions as per guidance by WHO. Therefore drug addiction means substance dependence.

Two basic concepts are described and defined to understand dependence – behavioural(psychological) dependence and physical dependence. In behavioural dependence, substance (drug) seeking activities and pathological (abnormal) use patterns are emphasized e.g. obtaining the drug from illegal means, the constant preoccupation of drug and consumption etc. Physical dependence refers to the physical (physiological) effects of multiple episodes of substance use. Addiction concept can be extended to other addictions e.g. Television addition, mobile addition, social media addiction, money addiction, gambling, stealing etc. These various addictions may have similar effects on the activities of specific ‘reward areas’ of the brain, such as the ventral tegmental area, locus ceruleus, and nucleus accumbens.

Dependence / addiction

Can be physical or psychological or both, e.g. psychological dependence also referred to as habituation, is characterized by a continuous or intermittent craving for the drug (substance). Therefore it is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, occurring within a period of 12 months. This behavioural change includes –

(1) recurrent substance use resulting in a failure to fulfil major obligation at work, school, or home; e.g. repeated absences or poor work performance, suspension or expulsion from school or work due to addiction etc.

(2) recurrent substance use in a situation in which it is physically hazardous (e.g. driving an automobile or operating a machine)

(3) recurrent substance-related legal problems (arrest or disorderly conduct)

(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused due to the effect of a substance ( physical fights, arguments etc).

The criteria for substance dependence include concept of tolerance ( need for increased amount of drug/ substance to achieve intoxication or desired effect and the effect of the substance decreases if a lesser quantity is consumed) and withdrawal ( clinical manifestation when the substance is withdrawal or stopped; this can vary from drug to drug e.g. alcohol, sedatives, narcotics etc) and few other diagnostic criteria like persistent desire and unsuccessful attempts to cut down or control drug use, important social, occupational activities are compromised, medical complication due to drug addiction.

Aetiology

There are various behaviour theories, genetic factors, neurochemical factors and comorbidity (presence of other medical or psychological condition) which has an effect on drug addiction.

The list of the drug-addicted or substance-related disorder is exhaustive and unending. If other addictions or non-drug addictions are included the spectrum of addiction is expanding e.g mobile games, computer, social media, selfie addiction etc. Common drug addiction list ( for which patients seek experts help) includes –

Alcohol

Amphetamine

Caffeine

Cannabis

Cocaine

Hallucinogens

Inhalant

Nicotine

Opioid

Phencyclidine

Sedative-hypnotic or anxiolytic

Anabolic steroids

Other substance-related disorders ( gamma hydroxybutyrate, nitrite inhalants, nitrous oxide etc.

The clinical picture, signs and symptoms depend on substance abuse. Sometimes there can be polysubstance abuse (more than one drug is used e.g. alcohol and cannabis). The symptom severity also varies from patient to patient. The correct diagnosis and pathological testing are prerequisites for further treatment protocol.

*Treatment and Rehabilitation*

The treatment protocol is mandatory in all major addition and it depends on the substance abused, duration of addiction, quantity consumed in a day, tolerance, dependence, withdrawal, personality factors or disorders, comorbid condition etc. Patients personality, willingness, insight and underlined other psychiatric disorder like depression, schizophrenia, mania determines the outcome of treatment. Apart from pharmacotherapy for de-addiction, various behaviour therapy models are used in such cases. Individual therapy, family therapy, group therapy, relapse prevention are few of the important therapies in rehabilitation along with pharmacotherapy.

Drug addiction is, therefore, a specific psychiatric disorder and requires proper care and treatment.

Anxiety Disorders

Anxiety disorders are the most common psychiatric disorders in India. The symptoms of anxiety have two components: the awareness of the physiological sensations (palpitations and sweating ) and the awareness of being nervous or frightened. Anxiety affects the motor and visceral functions as well as it affects thinking, perception and learning. Anxiety has a great impact on emotion, attention and concentration.

Epidemiological studies have shown that one in four people meet the diagnostic criteria for anxiety disorders and women are more likely to have an anxiety disorder than men. There are a lot of psychological- psychoanalytic and cognitive- behavioural, existential and biological theories about causes of anxiety.

From a psychiatric point of view, anxiety disorders are classified into 

(1) Panic disorder

(2) Specific and social phobias

(3) Obsessive-compulsive disorder 

(4) Post-traumatic stress disorder (PTSD)

(5) Generalised anxiety disorder

(6) Anxiety disorders due to a general medical condition

(7) Substance-induced anxiety disorder

(8) Anxiety disorder not otherwise specified.

Panic disorder is characterized by the spontaneous, unexpected occurrence of panic attacks that consists of discrete periods of intense fear varying from several attacks in a day to only a few attacks during a year. Panic disorder is often accompanied by agoraphobia, the fear of being alone in public places.

It is a very common disorder with prevalent in all age groups though females are affected more frequently. A panic attack is a key feature of this disorder and criteria for a panic attack is –

A discrete period of intense fear or discomfort, with few (at least four) of following symptoms which develop abruptly and reaches a peak within ten minutes.

(1) palpitations, pounding heart, or accelerated heart rate

(2) sweating

(3) trembling or shaking

(4) shortness of breath

(5) feeling of choking

(6) chest pain or discomfort 

(7) nausea or abdominal distress

(8) feeling dizzy, unsteady, lightheaded, or faint

(9) the feeling of unreality or feeling of being detached from oneself

(10) fear of losing control or going crazy

(11) fear of dying

(12) numbness or tingling sensation

(13) chills or hot flushes

A panic attack can occur in other mental disorders like specific phobias, PTSD etc. In panic disorder, there are recurrent unexpected panic attacks for the duration of one month (at least) and there is persistent concern about having panic attacks. It can occur along with features of agoraphobia i.e. the fear of being in public places, particularly places from which a rapid exit would be difficult during the course of a panic attack. Depressive symptoms are often present in cases of panic disorder and agoraphobia and need special attention in the treatment programme.

Phobia

Phobia is excessive fear of special object, circumstances or situation. Social phobia is also termed as social anxiety disorder and have excess fears of humiliation or embarrassment in various social settings (public speaking, ‘shy bladder’). Phobias are the most common mental health disorder in India. A specific phobia can be excessive, unreasonable fear of flying, heights, animals, seeing blood, receiving injection while social phobias are marked and persistent fear of the social situation.

Obsessive-Compulsive Disorder –

The essential feature of OCD is a symptom of recurrent obsessions or compulsions sufficiently severe to cause marked distress to the person. The obsession and compulsion are time-consuming and interfere significantly with the person’s normal routine, occupational functioning, social activities and interpersonal relationship.

Obsession – recurrent and intrusive thought, feeling, idea or sensation, thus obsession is a mental event. Compulsion, on the other hand, is behaviour pattern and is described as conscious, standardized, recurrent behaviour (counting, checking, avoiding).

Post-traumatic stress disorder (PTSD) –

PTSD is a syndrome that develops after a person sees, is involved, or hears of an extreme traumatic stressor. The person reacts to this experience with fear and helplessness, persistently relives the event, and tries to avoid being reminded of it. In acute stress disorder, the disturbance lasts for 2 days and a maximum of 4 weeks of the traumatic event. The traumatic event can be assault, violence, riots, war, accidents i.e. the events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others.

Generalized anxiety disorder –

Persons who seem to be pathologically anxious about almost everything are classified in generalized anxiety disorder. In  G.A.D. there is excessive anxiety and worry about several events or activities, the worry is difficult to control and is associated with somatic symptoms. The primary symptoms of G.A.D. are anxiety, motor tension (shakiness, restlessness, headache), autonomic hyperactivity ( breathlessness, sweating, palpitations) and cognitive vigilance (irritability). Abdominal discomfort e.g. pain, diarrhoea are often misinterpreted for gastrointestinal illness.

Anxiety disorder due to a general medical condition –

There are many medical conditions which are associated with anxiety. Hyper and hypothyroidism, hypoparathyroidism, vitamin B12 deficiency, cardiac arrhythmias, hypoglycemia are few of the medical conditions which can cause panic attacks, generalised anxiety disorder or obsessions and compulsions.

Treatment

With proper and adequate treatment, most of the patients with different anxiety disorders have a dramatic improvement. The two most effective treatment strategies are pharmacotherapy and cognitive- behaviour therapy. Family and group therapy are sometimes advised with psychoeducation and counselling session for the entire family to understand the psychosocial difficulties of the disorder. Underlined depression, drug dependence or personality disorder needs special attention and care. Ketamine infusion therapy in experts hand helps to control the symptoms (of severe anxiety and distress) rapidly within few days as medication might take a few weeks for its therapeutic effect.

The overall prognosis (outcome) of anxiety disorder is usually very good.