This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare three 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.
The Impact of Substance Use Disorder: Prevalence, Predispositions, and Comorbidity by Alisa Huskey
Substance use, both cross-culturally and locally, affects a substantial part of the population, causing significant impairment of functioning and damage to several aspects of life. In fact, the primary hallmark of substance dependence asserts that use is continued “despite having a physical or psychological problem that is a result of continued use.” Drug abuse and dependence are associated with decreased mental health, and social and emotional functioning. Drug dependence is particularly impairing in these areas. Various mood, anxiety, and personality disorders have all been linked to drug use disorders. The directionality of this association is not always clear. Self-medication is a common hypothesis for the development of substance abuse, suggesting that individuals afflicted with mental disorders seek to alleviate their symptoms by turning to drugs and alcohol – both illicit and prescription. Childhood sexual abuse has also been shown to be a risk factor for substance use disorders.
The National Institute on Drug Abuse reports that in the US over 600 billion dollars is spent annually in drug-related crime, work loss, and healthcare costs. Alcohol and tobacco are used more frequently over the lifetime than any other drugs, which is not incredibly surprising, considering their legal and social acceptance. Estimates indicate that 84.9% of Americans use alcohol at some point in their life, with tobacco (cigarettes and smokeless tobacco) a close second at 80.6% of individuals. Annual costs related to alcohol and tobacco use are approximately 428 billion dollars in the US; 126 billion of these costs are health related, such as emergency room visits, treatment programs, and other various associated costs. Marijuana (39.1%) and Cocaine (14.4%) are the most frequently use illicit drugs. Non-medical use of psychotherapeutic drugs (19.1%) and pain relievers (15.4%) have high usage rates as well. It is important to note that these rates do not exemplify the number of people qualifying for a substance use disorder (i.e., an addiction).
Addiction is commonly described as the “continued repetition of a behavior despite adverse consequence or a neurological impairment leading to such behavior” Addiction has physiological, psychological, and sociological components. Contrary to popular belief, addiction is not solely a physiological dependence upon a substance. In fact, the diagnostic criteria for Substance Abuse (SA) and Substance Dependence (SD) Disorders also include primarily social and psychological criteria. In the latest edition of the DSM (5), the diagnoses of SA and SD were rolled into one category labeled Substance Use Disorders (SUD).
In the U.S. during any given year, approximately 1.4% and 0.6% of the population could qualify for substance abuse and substance dependence disorders, respectively. Lifetime prevalence rates for each are around 7.7% and 2.6%, respectively (lifetime prevalence rates indicate the number of individuals likely to qualify for a particular disorder at some point during their life). Unsurprisingly, alcohol is the most commonly diagnosed SUD, with prevalence rates estimated at 13.4% for lifetime. Hispanics have the highest lifetime prevalence rates (approx. 13.3%) for any substance, with whites following as a close second (approx. 12.5%). Substance abuse and dependence rates among Native Americans are the highest, with 18.4% developing some kind of substance problem over their lifetime.
Research indicates that drug problems are more likely to occur if you are a white, single (never-married, widowed, separated, or divorced), low-income man. However, Native American men have higher rates than white men. The development of a drug related disorder typically occurs before or around age 19, whereas development after the age of 25 is very uncommon. Overall, men have higher rates of substance use problems (lifetime – 13.8%; 12-month – 2.8%) than women (lifetime – 7.1%; 12-month – 1.2%). In adolescents, boys are more prone than girls to have drug and alcohol problems as well.
Comorbidity with other psychological disorders is very common in substance use disorders. When diagnoses exist simultaneously, it is known as comorbidity. For example, adolescents raised in tumultuous environments are at a higher risk of developing problems with substance use comorbid with mood or anxiety disorders. The use of substances is often used as a form of self-medication in an attempt to alleviate emotional pain brought on by depression or anxiety (or things of the like). SUDs are roughly two times more likely to occur in individuals with a mood or anxiety disorder, and vice versa. At times, it is difficult to determine which disorder contributed to the development of the other
It’s important to note that self-medication of emotional and psychological problems is not always the motivation behind substance use. The study of what causes the development of a disorder is known as etiology. Etiological factors of comorbidity with SUD can be very complex. For example, the comorbidity of schizophrenia and marijuana, discovering whether the chicken or the egg came first is more difficult. Marijuana use begins before, during and after the onset of schizophrenia; thus, it is difficult to decipher whether marijuana is a trigger for schizophrenia, or whether it is a form of self-medication for the schizophrenic symptoms or side-effects of the medication for the disorder. It has also been suggested that certain mechanisms underlie the development of both.
Developmental factors are implicated in the development of Comorbid Disorders because drug use during brain development (adolescence) can contribute to the development of a mental disorder. Early onset of other mental disorders can also lead to the development of a substance problem. Some research suggests certain genetic and neurological predispositions underlie the development of SUDs. Some of these predispositions are thought to be agitated or initiated by certain environmental cues. While the etiology of disorders can be difficult to assess, it can be very beneficial for treatment as well as for future research of the disorder. As a therapist, for example, understanding the directionality of the relationship between anxiety, mood, and substance use disorders can guide treatment. If the mood or anxiety disorder was the trigger for the substance problems, then treating the client for that is just as imperative as treating them for the SUD.