Disorders Due to Psychoactive Disorders Due to Psychoactive Substance UseSubstance Use

Department of PsychiatryDepartment of Psychiatry

11stst Faculty of Medicine Faculty of Medicine

Charles University, PragueCharles University, Prague

Head: Prof. MUDr. Jiří Raboch, DrSc.Head: Prof. MUDr. Jiří Raboch, DrSc.

Psychoactive SubstancePsychoactive Substance

Psychoactive (psychotropic)Psychoactive (psychotropic) substancesubstance is any substance which after is any substance which after absorption has influence on mental absorption has influence on mental processes both cognitive and processes both cognitive and affectiveaffective..

1.1. stimulativestimulative

2.2. suppressivesuppressive

3.3. hallucinogenichallucinogenic

Mental and Behavioural Disorders Mental and Behavioural Disorders Due to Psychoactive Substance UseDue to Psychoactive Substance Use

Disorders due to use ofDisorders due to use of::

F10.F10.x x alcoholalcohol

F11.F11.xx opioidsopioids

F12.F12.x x cannabinoidscannabinoids

F13.F13.xx sedatives or hypnoticssedatives or hypnotics

F14.F14.x x cocainecocaine

F15.F15.x x other stimulants (caffeine)other stimulants (caffeine)

F16.F16.x x hallucinogenshallucinogens

F17.F17.x x tobaccotobacco

F18.F18.xx volatile solventsvolatile solvents

F19.F19.xx multiple drugs and othermultiple drugs and other

psychoactive drugspsychoactive drugs

Mental and Behavioural Disorders Mental and Behavioural Disorders Due to Psychoactive Substance UseDue to Psychoactive Substance Use

Specific Clinical ConditionsSpecific Clinical Conditions::F1x.0 Acute intoxicationsF1x.0 Acute intoxicationsF1x.1 Harmful useF1x.1 Harmful useF1x.2 Dependence syndromeF1x.2 Dependence syndromeF1x.3 Withdrawal stateF1x.3 Withdrawal stateF1x.4 Withdrawal state with deliriumF1x.4 Withdrawal state with deliriumF1x.5 Psychotic disorderF1x.5 Psychotic disorderF1x.6 Amnesic syndromeF1x.6 Amnesic syndromeF1x.7 Residual state, late-onset psychotic F1x.7 Residual state, late-onset psychotic

disorderdisorderF1x.8 Other mental and behavioural disordersF1x.8 Other mental and behavioural disordersF1x.9F1x.9 Unspecified mental and behavioural Unspecified mental and behavioural

disorderdisorder

F1x.0 Acute IntoxicationF1x.0 Acute IntoxicationDf.: Df.: A transient condition following the administration A transient condition following the administration

of psychoactive substance resulting in of psychoactive substance resulting in disturbances in level of consciousness, cognition, disturbances in level of consciousness, cognition, perception, affect or behaviour, or other perception, affect or behaviour, or other psychophysiological functions and responsespsychophysiological functions and responses

Closely related to dose levelsClosely related to dose levels

UncomplicatedUncomplicated With trauma or other medical complicationsWith trauma or other medical complications With deliriumWith delirium With comaWith coma With convulsionsWith convulsions Pathological intoxicationPathological intoxication (applies only to (applies only to

alcohol)alcohol)

F1x.1 Harmful UseF1x.1 Harmful Use

The damage may be physical and/or mental.The damage may be physical and/or mental. Socially negative consequences are not Socially negative consequences are not

evidence (neither acute intoxication or evidence (neither acute intoxication or hangover).hangover).

F1x.2 Dependence Syndrome F1x.2 Dependence Syndrome (Addiction)(Addiction)

a)a) A strong desire or sense of compulsion to A strong desire or sense of compulsion to take the substance („craving“)take the substance („craving“)

b)b) Difficulties in controlling substance-takingDifficulties in controlling substance-takingc)c) Withdrawal sy characteristic for the Withdrawal sy characteristic for the

substancesubstanced)d) Evidence of toleranceEvidence of tolerancee)e) Progressive neglect of pleasures and Progressive neglect of pleasures and

interestsinterestsf)f) Persisting with substance use despite clear Persisting with substance use despite clear

evidence of overtly harmful consequencesevidence of overtly harmful consequences

Physical dependencePhysical dependence Psychic (psychological) dependencePsychic (psychological) dependence

F1x.2 The Course of Dependence F1x.2 The Course of Dependence SyndromeSyndrome

F1x.20F1x.20 currently abstinent (remission) currently abstinent (remission)

F1x.21 F1x.21 currently abstinent in a protected currently abstinent in a protected environmentenvironment

F1x.22 F1x.22 currently abstinent on a maintenance currently abstinent on a maintenance regimeregime

F1x.23 F1x.23 currently abstinent - receiving treatment currently abstinent - receiving treatment with aversive or blocking drugs with aversive or blocking drugs (naltrexone, disulfiram)(naltrexone, disulfiram)

F1x.24 F1x.24 currently active dependencecurrently active dependence

F1x.25F1x.25 continuous (chronic) use continuous (chronic) use

F1x.26 F1x.26 episodic use (dipsomania)episodic use (dipsomania)

F1x.3 Withdrawal StateF1x.3 Withdrawal State

Symptoms occurring on absolute or Symptoms occurring on absolute or relative withdrawal of a substance relative withdrawal of a substance after repeated and prolonged use of after repeated and prolonged use of the substancethe substance

• UncomplicatedUncomplicated• With convulsionsWith convulsions

F1x.4 Withdrawal State with F1x.4 Withdrawal State with DeliriumDelirium

Delirium tremensDelirium tremens - in severely - in severely dependent users with a long history of dependent users with a long history of use of alcoholuse of alcohol

Prodromal symptomsProdromal symptoms: insomnia, : insomnia, tremor, fears followed by illusions, tremor, fears followed by illusions, hallucinations, clouding of hallucinations, clouding of consciousness and marked tremorconsciousness and marked tremor

F1x.5 Psychotic DisorderF1x.5 Psychotic Disorder

Psychotic phenomena occurring during or Psychotic phenomena occurring during or immediately after psychoactive substance immediately after psychoactive substance useuse

Schizophrenia-likeSchizophrenia-like Predominantly delusional, hallucinatory, Predominantly delusional, hallucinatory,

depressive, manicdepressive, manic (alcoholic hallucinosis, (alcoholic hallucinosis, jealousy) jealousy)

Persistence for more than 48 hoursPersistence for more than 48 hours

F1x.6 Amnesic SyndromeF1x.6 Amnesic Syndrome Impairment of recent memoryImpairment of recent memory (learning of new (learning of new

material)material) Absence of defect in immediate recall, of Absence of defect in immediate recall, of

impairment of consciousness, and of impairment of consciousness, and of generalized cognitive impairmentgeneralized cognitive impairment

History of chronic use of psychoactive History of chronic use of psychoactive substancesubstance (Korsakov’s psychosis or syndrome) (Korsakov’s psychosis or syndrome)

F1x.7 F1x.7 Residual and late-onset Residual and late-onset psychotic disorder psychotic disorder

Onset related to the use of psychoactOnset related to the use of psychoactiveive substance, the disorder should persist beyond substance, the disorder should persist beyond any period of time during which direct effects any period of time during which direct effects of the psychoactive substance might be of the psychoactive substance might be assumedassumed

FlashbacksFlashbacks - duration in seconds or minutes, - duration in seconds or minutes, duplication of previous drug-related duplication of previous drug-related experiencesexperiences

Personality disorderPersonality disorder DementiaDementia

F10.x Mental Disorders Due to F10.x Mental Disorders Due to Use of AlcoholUse of Alcohol

Acute intoxicationAcute intoxication::• euphoria, flushed face, ataxia, slowed reaction euphoria, flushed face, ataxia, slowed reaction

time, impaired motor performance, slurred time, impaired motor performance, slurred speech, poor concentration; in higher doses speech, poor concentration; in higher doses behavioural changes – disinhibition of sexual and behavioural changes – disinhibition of sexual and aggressive impulses, increased suicidal and aggressive impulses, increased suicidal and homicidal behaviourhomicidal behaviour

Pathological intoxicationPathological intoxication::• sudden change of consciousness with aggressive sudden change of consciousness with aggressive

behaviour and amnesiabehaviour and amnesia Harmful useHarmful use::

• physical complications – hypertension, physical complications – hypertension, arteriosclerosis, heart infarction, cardiomyopathy, arteriosclerosis, heart infarction, cardiomyopathy, brain stroke, liver cirrhosis, fatty liver, gastritis, brain stroke, liver cirrhosis, fatty liver, gastritis, etc.etc.

• psychic complications - depressionpsychic complications - depression

F10.x Mental Disorders Due to F10.x Mental Disorders Due to Use of AlcoholUse of Alcohol

Dependence syndrome:Dependence syndrome:• increased tolerance to alcohol, morning increased tolerance to alcohol, morning

drinking, alcohol bouts, blackouts, drinking, alcohol bouts, blackouts, deterioration in occupational and marital life, deterioration in occupational and marital life, behavioural changes, withdrawal symptomsbehavioural changes, withdrawal symptoms

Withdrawal state:Withdrawal state:• tremor, anxiety, easy getting startled, tremor, anxiety, easy getting startled,

agitation, insomnia, nausea, sweating, agitation, insomnia, nausea, sweating, epileptic seizures and delirium tremensepileptic seizures and delirium tremens

Delirium tremens:Delirium tremens:• usually starts in evening hours – growing usually starts in evening hours – growing

tremulousness, severe agitation, anxiety and tremulousness, severe agitation, anxiety and perceptual distortionperceptual distortion

• a state seriously endangering patient's lifea state seriously endangering patient's life• recovery after several days, retrograde recovery after several days, retrograde

amnesiaamnesia

F10.x Mental Disorders Due to F10.x Mental Disorders Due to Use of AlcoholUse of Alcohol

Other psychotic disorders:Other psychotic disorders:• alcoholic hallucinosisalcoholic hallucinosis• pathological jealousypathological jealousy• Korsakov's psychosisKorsakov's psychosis• Wernicke encephalopathyWernicke encephalopathy• alcoholic dementiaalcoholic dementia

Treatment of alcoholismTreatment of alcoholism• Withdrawal from alcohol, benzodiazepines, Withdrawal from alcohol, benzodiazepines,

clomethiazolclomethiazol• Aversion therapyAversion therapy• Alcohol-Antabuse (disulfiram) Reaction (AAR)Alcohol-Antabuse (disulfiram) Reaction (AAR)• PsychotherapyPsychotherapy

F11.x Mental Disorders Due to F11.x Mental Disorders Due to Use of OpioidsUse of Opioids

Morphine, heroin (diacetylmorphine), Morphine, heroin (diacetylmorphine), codeine, pethidine, methadonecodeine, pethidine, methadone

HeroinHeroin::• dependence develops within two weeks of dependence develops within two weeks of

daily usedaily use• overdose may lead to deathoverdose may lead to death• withdrawal symptoms are extremely withdrawal symptoms are extremely

unpleasantunpleasant• needle-sharing represents a serious risk of needle-sharing represents a serious risk of

transmission of HIV and hepatitransmission of HIV and hepatititis B + C virusess B + C viruses• treatment of the withdrawal state – treatment of the withdrawal state –

buprenorphine, benzodiazepines, spasmolytics; buprenorphine, benzodiazepines, spasmolytics; in serious cases of dependence heroin is in serious cases of dependence heroin is replaced by methadone replaced by methadone

F1F122.x Mental Disorders Due to .x Mental Disorders Due to Use of Use of CannabinoidsCannabinoids

MarijuanaMarijuana (marihuana) is a colloquial term for dried leaves and (marihuana) is a colloquial term for dried leaves and flowers of cannabis plant (flowers of cannabis plant (Cannabis sativaCannabis sativa L.) L.)

ΔΔ99-tetrahydrocannabinol (Δ-tetrahydrocannabinol (Δ99-THC)-THC) is responsible for the is responsible for the psychoactive properties of the cannabis plant psychoactive properties of the cannabis plant

Complex physiological functions of the cannabinoid system: Complex physiological functions of the cannabinoid system: motor coordination, memory procession, control of appetite, motor coordination, memory procession, control of appetite, pain modulation and neuroprotectionpain modulation and neuroprotection

Summary of adverse effects:Summary of adverse effects:• acuteacute: anxiety, panic, impaired attention, memory, reaction : anxiety, panic, impaired attention, memory, reaction

time and psychomotor performance and coordination, time and psychomotor performance and coordination, increased risk of road accident, and increased risk of increased risk of road accident, and increased risk of psychotic symptoms among vulnerable personspsychotic symptoms among vulnerable persons

• chronicchronic: chronic bronchitidis, a cannabis dependence : chronic bronchitidis, a cannabis dependence syndrome, subtle impairments of attention, short-term syndrome, subtle impairments of attention, short-term memory and ability to organize and integrate complex memory and ability to organize and integrate complex informationinformation

F1F122.x Mental Disorders Due to .x Mental Disorders Due to Use of Use of CannabinoidsCannabinoids

Effect of cannabinoids on central nervous system:Effect of cannabinoids on central nervous system: Euphoria, enhancement of sensory perception, tachycardia, Euphoria, enhancement of sensory perception, tachycardia,

antinociception, difficulties in concentration, impairment of antinociception, difficulties in concentration, impairment of memorymemory

Cannabis use may exacerbate symptoms of schizophrenia Cannabis use may exacerbate symptoms of schizophrenia and may precipitate disorders in persons who are and may precipitate disorders in persons who are vulnerable to developing psychosis; heavy cannabis use vulnerable to developing psychosis; heavy cannabis use may increase depressive symptoms among some usersmay increase depressive symptoms among some users

Tolerance develops; the relatively long half-life and Tolerance develops; the relatively long half-life and complex metabolism of cannabis may result in a low complex metabolism of cannabis may result in a low intense withdrawal syndrome intense withdrawal syndrome

Marijuana use tends to impair executive function in the Marijuana use tends to impair executive function in the brain, e.g. higher risk for all types of injuries is associated brain, e.g. higher risk for all types of injuries is associated with cannabis use with cannabis use

Cannabis abuse and dependence were highly associated Cannabis abuse and dependence were highly associated with increasing risks of other substance dependencewith increasing risks of other substance dependence

F13.x Mental Disorders Due to F13.x Mental Disorders Due to Use of Sedatives and HypnoticsUse of Sedatives and Hypnotics

benzodiazepinesbenzodiazepines – potentiate the action of – potentiate the action of GABAGABA

risk of dependencerisk of dependence short-acting benzodiazepines: alprazolam, short-acting benzodiazepines: alprazolam,

flunitrazepam, oxazepam, lorazepam, flunitrazepam, oxazepam, lorazepam, temazepamtemazepam

long-lasting benzodiazepines: diazepam, long-lasting benzodiazepines: diazepam, clorazepate, chlordiazepoxide, etc.clorazepate, chlordiazepoxide, etc.

withdrawal state can be accomplished with withdrawal state can be accomplished with epileptic seizuresepileptic seizures

interaction with alcohol may induce interaction with alcohol may induce qualitative changes of consciousnessqualitative changes of consciousness

F14.x,15.x Mental Disorders F14.x,15.x Mental Disorders Due to Use of StimulantsDue to Use of Stimulants

Cocaine, amphetamine, metamphetamine Cocaine, amphetamine, metamphetamine (pervitine), phenmetrazine, methyphenidate, (pervitine), phenmetrazine, methyphenidate, MDMA (ecstasy, MDMA (ecstasy, methylenedioxymetamphetamine)methylenedioxymetamphetamine)

Positive mood, activity, planning, diminished Positive mood, activity, planning, diminished need of sleepneed of sleep

Tachycardia, arrhythmia, hypertension, Tachycardia, arrhythmia, hypertension, hyperthermia, intracerebral haemorrhagehyperthermia, intracerebral haemorrhage

Withdrawal symptoms: severe craving, Withdrawal symptoms: severe craving, depression, decreased energy, fatigue, sleep depression, decreased energy, fatigue, sleep disturbancedisturbance

Prolonged use can trigger paranoid psychoses, Prolonged use can trigger paranoid psychoses, impulsivity, aggressivity, irritability, impulsivity, aggressivity, irritability, suspiciousness and anxiety statessuspiciousness and anxiety states

F16.x Mental Disorders Due to F16.x Mental Disorders Due to Use of HallucinogensUse of Hallucinogens

Lysergid acid diethylamide (LSD), Lysergid acid diethylamide (LSD), psilocybin, mescaline, phencyclidinepsilocybin, mescaline, phencyclidine

Acute intoxication: distorted perception Acute intoxication: distorted perception (optic hallucinations and illusions); (optic hallucinations and illusions); unpredictable and dangerous behaviourunpredictable and dangerous behaviour

Withdrawal syndrome has not been Withdrawal syndrome has not been describeddescribed

F18.x Mental Disorders Due to F18.x Mental Disorders Due to Use of Volatile SolventsUse of Volatile Solvents

Toluene, acetone, adhesives, petrol, Toluene, acetone, adhesives, petrol, cleaning fluids, etc.cleaning fluids, etc.

Acute intoxication: euphoria, Acute intoxication: euphoria, disorientation, incoordination, slurred disorientation, incoordination, slurred speech; optic hallucinationsspeech; optic hallucinations

The way of use is very dangerousThe way of use is very dangerous

Drug Addiction TreatmentDrug Addiction TreatmentHEALTH SERVICEHEALTH SERVICE:: acute states (detox program, tox. psychosis)acute states (detox program, tox. psychosis) weaning treatmentweaning treatment after-treatment care after-treatment care substitution (maintainance) treatmentsubstitution (maintainance) treatment

OUT OF HEALTH SERVICEOUT OF HEALTH SERVICE:: contact centerscontact centers daily static centers daily static centers therapeutic communitiestherapeutic communities after-treatment centersafter-treatment centers protected workshops and habitationsprotected workshops and habitations mutual help groups – Alcoholics Anonymous, mutual help groups – Alcoholics Anonymous,

Narcotics AnonymousNarcotics Anonymous

LinksLinks

Czech National Focal Point for Drugs Czech National Focal Point for Drugs and Drug Addiction:and Drug Addiction:

www.drogy-info.czwww.drogy-info.cz European Monitoring Centre for European Monitoring Centre for

Drugs and Drug Addiction:Drugs and Drug Addiction:

http://http://www.emcdda.eu.intwww.emcdda.eu.int//