Seminar on Substance use: Terms used in Substance related disorders Historical background DSM 5 and ICD 10 diagnosis Etiology of substance use

1. Prepared by: Deepanwita Roy, 1st Year M.Phil Trainee, University of Calcutta

2. Introduction
 The presentation of alcohol and drug misuse is not limited to
any particular psychiatric or indeed medical specialty. Alcohol
and drug use may play an important part in all aspects of
psychiatric practice, and is relevant.
 The phrases Substance Use Disorder (DSM IV) or
Substance-Related and Addictive disorders (DSM V) or
Mental and behavioral disorders due to psychoactive
substance use (ICD 10) are used to refer to conditions arising
from the misuse of alcohol, psychoactive drugs, or other
chemicals such as volatile substances.
 According to Reber’s dictionary of psychology (2000),
substance is a drug.

3.  Substance/Drug:
The term substance can refer to a drug that has either positive or
negative affect on mental functioning. A drug is any chemical
substance that has the ability to alter our biological system.
In psychology, we basically deal with psychoactive drugs or
substances .
In pharmacology, a drug is a chemical substance used in
treatment, cure, prevention, or diagnosis of disease or used to
enhance physical or mental well-being.
 Psychoactive drugs/substances:
Psychoactive drugs/substances are which affect brain functions ,
mood and behaviour. A psychoactive drug is a substance that
affects mental functioning and act on the nervous system to alter
states of consciousness, modify perceptions, and change moods.
It typically activates dopamine receptors in the reward pathway of
the brain.

4. Terms used in
Substance Related Disorders
 Dependence: The repeated use of a drug or chemical
substance, with or without physical dependence. Physical
dependence indicates an altered physiological state due to
repeated administration of a drug, the cessation of which
results in a specific syndrome.
 Abuse: Use of any drug, usually by self-administration, in a
manner that deviates from approved social or medical patterns.
 Misuse: Similar to abuse but usually applies to drugs
prescribed by physicians that are not used properly.
 Addiction: The repeated and increased use of a substance,
the deprivation of which gives rise to symptoms of distress and
an irresistible urge to use the agent again and which leads also
to physical and mental deterioration. The term is no longer
included in the official nomenclature, having been replaced by
the term Dependence, but it is a useful term in common
usages.

5.  Intoxication: A reversible syndrome caused by a specific
substance that affects one or more of the following mental
functions: memory, orientation, mood, judgment, and
behavioral, social, or occupational functioning.
 Withdrawal: A substance-specific syndrome that occurs after
stopping or reducing the amount of the drug or substance that
has been used regularly over a prolonged period of time. The
syndrome is characterized by physiological signs and
symptoms in addition to psychological changes such as
disturbances in thinking, feeling, and behavior. Also called
abstinence syndrome or discontinuation syndrome.
 Tolerance: Phenomenon in which, after repeated
administration, a given dose of drug produces a decreased
effect or increasingly larger doses must be administered to
obtain the effect observed with the original dose. Behavioral
tolerance reflects the ability of the person to perform tasks
despite the effects of the drug.

6.  Cross-tolerance: Refers to the ability of one drug to be
substituted for another, each usually producing the same
physiological and psychological effects (e.g., diazepam and
barbiturates). Also known as cross-dependence.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Text rev. (DSM-IV-TR) Washington, DC: American Psychiatric
Association; copyright 2000, with permission.

8. 1932
• The American Psychiatric Association (APA) created a
definition of Drug Use and Abuse that used legality, social
acceptability, and cultural familiarity as qualifying factors.
1952
• First edition of Diagnostic and Statistical Manual of Mental
Disorder (DSM-I) was published which grouped alcohol and
drug abuse under Sociopathic Personality Disturbances, which
were thought to be symptoms of deeper psychological disorders
or moral weakness.
1966
• American Medical Association's Committee on Alcoholism and
Abuse defined ‘abuse’ of stimulants (amphetamines, primarily) in
terms of 'medical supervision’**
1980
• DSM-III was the first to bring in social and cultural factors. The
definition of ‘substance dependence’ emphasized tolerance to
drugs, and withdrawal from them as key components to
diagnosis, whereas ‘substance abuse’ was defined as
"problematic use with social or occupational impairment" but
without withdrawal or tolerance.

9. 1987
• DSM-III-R included the category “psychoactive
substance abuse”, redefined with equal weight and
emphasis to behavioral and physiological factors in
diagnosis.
1994
• DSM-IV defined substance dependence as "a syndrome
involving compulsive use, with or without tolerance and
withdrawal"; whereas substance abuse is "problematic
use without compulsive use, significant tolerance, or
withdrawal."
2000
• The DSM-IV-TR, defines substance dependence as "when
an individual persists in use of alcohol or other drugs
despite problems related to use of the substance, substance
dependence may be diagnosed." followed by criteria for the
diagnosis.

10. The two classification systems, DSM and ICD, use
similar categories for substance related disorders but
group them in different ways.

11. DSM-5
Substance Use Disorder
Substance Intoxication
Substance Withdrawal
Substance-Induced Mental
Disorder
ICD-10
Acute Intoxication
Harmful use
Dependence syndrome
Withdrawal state
Withdrawal state with delirium
Psychotic Disorder
Amnestic syndrome
Residual and late-onset psychotic
disorder
Other mental and behavioral disorder
Unspecified mental and behavioral
disorder

12.  CHANGE FROM DSM-IV TO DSM-V:
 DSM-V does not separate the diagnoses of substance abuse and
substance dependence.
 Criteria are provided for substance use disorder accompanied by criteria
for intoxication, withdrawal, substance induced disorder and unspecified
substance related disorder.
 Within substance use disorder, the DSM-IV recurrent substance related
legal problems criterion has been deleted from DSM-V and new criterion-
Strong desire or urge to use a substance has been added.
 SUBSTANCE RELATED DISORDERS IN ICD-10 & DSM IV-TR
 ICD-10 uses the term disorders due to psychoactive substance abuse
where as DSM-IV uses substance related disorders.
 ICD-10 considers all the disorders in one common list but DSM-IV
divides them into 2 groups :
1) substance use disorders – a) dependence b) abuse;
2) substance induced disorders.
 Substance abuse disorders of DSM-IV is a wide concept where as
harmful use category of ICD-10 is a restrictive concept.
 The substance induced disorders category of DSM IV additionally
includes sleep disorders and sexual dysfunctions as specific category.

13. Classification of Substances
In both diagnostic systems the first step in classification is to
specify the substance or class of substance that is involved
(Table below); this provides the primary diagnostic category.
DSM-V ICD-10
Alcohol-Related Disorder Use of Alcohol
Caffeine-Related Disorder Use of other stimulants including caffeine
Cannabis-Related Disorder Use of Cannabinoids
Hallucinogen-Related Disorder Use of Hallucinogens
Inhalant-Related Disorder Use of Volatile Solvents
Opioid-Related Disorder Use of Opioids
Sedative-, Hypnotic-, or Anxiolytic-Related
Disorder
Use of Sedatives or Hypnotics
Stimulant-Related Disorder Use of Cocaine
Tobacco-Related Disorder Use of Tobacco

14. The etiology of substance related disorders is complex and multi factorial having
bio-psycho-social components. Over the past few decades, the disease concept
of substance use disorders, particularly alcoholism has become well accepted

16. Genetic Studies
Most of the information on genetics are related to alcoholism;
 Family studies:
 If traits “run” in families, it is thought that because family
members share genes, there may be evidence of a genetic
basis for the traits.
 Rates of alcoholism is substantially higher in relatives of
alcoholics than in non-alcoholics, demonstrating 3-4 times
increased risk for developing the disorder, as compared to
other children (Schuckit,1987).
 Approximately 25% of sons of alcoholics become alcoholics,
also, nearly 33% of alcoholics had at least one parent who
abused alcohol; thus, alcohol abuse is familial (Collins &
deFiebre, 1990; Crabbe et al., 1985).

17.  Twin Studies:
 Monozygotic twins have been found to have higher
concordance for alcoholism than dizygotic twins in most of the
studies (Crabbe et al., 1985) with an estimated heritability of
about 50% (Blenvenu et.al.,2011; Kay, 1960).
 Adoption Studies:
 Children of alcoholic parents who had been adopted by non-
alcoholic parents were nearly 4 times more likely to have
alcohol problems than the group of children whose real parents
were non-alcoholic (Goodwin et al., 1999).
 Same study compared alcoholic parents’ sons who were
adopted by non-alcoholic parents with sons raised by their own
alcoholic parents found 25% and 17% of rates of alcoholism
respectively.

18.  Adoption studies have identified a genetic predisposition
toward two types of alcohol abuse and dependence in males:
the milieu type and the male limited type.
The milieu type is characterized by mild alcohol abuse, minimal
criminality, and no history of treatment for alcohol abuse by the
biological parents. The male-limited type is characterized by
severe alcoholism, high criminality, and history of treatment by the
biological father for alcohol abuse. (Cloninger et.al 1988).
 Linkage Studies:
Allelic association studies have focused in particular on the alleles
of genes that affect alcohol metabolism because, it has been
seen that, people with impaired activity of the alcohol
metabolizing enzymes, Aldehyde Dehydrogenase (ALDH2) have
unpleasant reactions when they consume alcohol and are
therefore at significantly lower risk of alcohol dependence. At a
molecular level, a point mutation in the gene for a form of ALDH2
renders the enzyme inactive; this mutation is less common in
people with alcohol dependence. Subsequently, linkage analysis
has confirmed that mutations in the genes that code for ALDH2
protect against harmful drinking (Foroud et.al 2010).

19. Selective functions of brain
The development of addiction involve a simultaneous process of
 increased focus on and engagement in a particular
behaviour and
 the attenuation or "shutting down" of other behaviours.
For example, under certain experimental circumstances such
as social deprivation and boredom, animals allowed the unlimited
ability to self-administer certain psychoactive drugs will show such
a strong preference that they will forgo food, sleep, and sex for
continued access.
The neuro-anatomical correlate of this is that the brain regions
involved in driving goal-directed behaviour grow increasingly
selective for particular motivating stimuli and rewards, to the point
that the brain regions involved in the inhibition of behavior can no
longer effectively send "stop" signals.
In this case, the limbic system is thought to be the major "driving
force" and the orbito-frontal cortex is the substrate of the top-down
inhibition.

20. The human body has a natural tendency to maintain homeostasis,
and the central nervous system is no exception. Chronic elevation
of dopamine will result in a decrease in the number of
dopamine receptors available in a process known as down
regulation. The decreased number of receptors changes the
permeability of the cell membrane located post-synaptically, such
that the post-synaptic neuron is less excitable-i.e.: less able to
respond to chemical signalling with an electrical impulse, or action
potential. It is hypothesized that this dulling of the responsiveness
of the brain's reward pathways contributes to the inability to feel
pleasure, known as anhedonia, often observed in addicts. The
increased requirement for dopamine to maintain the same
electrical activity is the basis of both physiological tolerance and
withdrawal associated with addiction.

21. Alcohol Flush Reaction
Alcohol flush reaction are abnormal physiological reactions to
alcohol marked by hypersensitive reaction including flushing of the
skin, a drop in blood pressure, heart palpitation and nausea
following the ingestion of alcohol caused by a mutant enzyme that
fails to break alcohol molecules down in the liver during metabolic
process, is mostly seen in Asians. The relatively lower rate of
alcoholism in Asians might be related to the extreme discomfort
associated with alcohol flush reactions, although cultural factors
may also play a role (Matsushita, et.al 1994).

22. NEUROBIOLOGY OF ABUSE
The Mesocorticolimbic Dopamine Pathway/Pleasure
Pathway:
• The MCLP is the center of psychoactive drugs in the brain.
• It is made up of axons or neuronal cells in the middle portion of
the brain known as ventral tegmental area and connect to the
other brain centers such as nucleus accumbens and then to
the frontal cortex.
• Alcohol produces euphoria by stimulating this area in the brain
and so as increasing dopaminergic activity in the same area
which tend to change the brain’s normal activity and activate
pleasure pathway. In this way brain reward systems are
reinforced, so further use is promoted (Liebman &
Cooper,1989; Littrell,2001).

24. Neurotransmitters Distribution in the
CNS
Functions Drugs that affect it
Dopamine Midbrain, Ventral
tegmental area
(VTA), Cerebral
cortex,
Hypothalamus
Pleasure and
reward movement,
attention, memory
All drugs of abuse
directly or indirectly
increases
dopamine in reward
pathway
Serotonin Midbrain, VTA,
Cerebral cortex,
Hypothalamus
Mood, Sleep,
Sexual desire,
Appetite
MDMA (ecstasy),
LSD, Cocaine
Norepinephrine Midbrain, VTA,
Cerebral cortex,
Hypothalamus
Sensory
processing,
Movement, Sleep,
Mood, Memory,
Anxiety
Cocaine,
Methamphetamine,
Amphetamine
Endogenous
opioids (endorphin
and enkephalin)
Widely distributed in
brain but regions
vary in type of
receptors, Spinal
cord
Analgesia,
Sedation, Rate of
bodily functions,
Mood
Heroin, Morphine,
Prescription
painkillers
(Oxycodone)
Role of Neurotransmitters

25. Neurotransmitters Distribution in the
CNS
Functions Drugs that affect it
Acetylcholine Hippocampus,
Cerebral cortex,
Thalamus, Basal
ganglia, Cerebellum
Memory, Arousal,
Attention, Mood
Nicotine
Endogenous
cannabinoids
(anandamide)
Cerebral cortex,
Hippocampus,
Thalamus, Basal
ganglia
Movement,
Cognition and
memory
Marijuana
Glutamate Widely distributed in
brain
Neuron activity
(increased rate),
Learning,
Cognition, Memory
Ketamine,
Phencyclidine,
Alcohol
Gamma-
aminobutyric acid
(GABA)
Widely distributed in
brain
Neuron activity
(slowed), Anxiety,
Memory,
Anesthesia
Sedatives,
Tranquilizers,
Alcohol
https://www.drugabuse.gov/news-events/nida-notes/2007/10/impacts-drugs-
neurotransmission

26.  Membrane Studies
A large part of the research on the membrane mechanisms for the
development of tolerance and dependence has been focusing on
substance induced changes in the membrane receptors and
intracellular signalling systems . In studies on acute effects,
glycine, NMDA, AMPA and kainate receptors have emerged as
the possible sites of alcohol actions. Some of these sites have
changed with chronic alcohol exposure, alongside changes in the
channels.
 Craving
Craving is an irresistible urge to use a substance that compels
drug seeking behaviour. Craving has been linked to the changes
in the concentrations of the neurotransmitters in the brains like
that of nucleus accumbens and hippocampus and which is one
anatomical sites suggested for craving because it is a seat for
learning, memory and conditioned responses. For example,
 dopamine and endorphins in regions like nucleus
accumbens and hippocampus has been associated with
craving for cocaine and stimulant use .
 changes in endorphins and serotonin levels have been
linked craving for alcohol.

28. PSYCHODYNAMIC VIEWPOINT
Early Psychodynamic Theories:
 Freud considered abuse/addiction as substitution for
regressive, infantile auto-eroticism, which was first experienced
as pleasurable then un-pleasurable, the vicious cycle of most
addiction. In this cycle wish for pleasure becomes gratified, but
only with accompanying guilt and loss of self esteem. These
feelings produce unbearable anxiety which in turn leads to
repetition of the act in order to find relief.
 Karl Abraham stressed the role of alcohol in reducing sexual
inhibitions in men. He theorized that male alcoholics have
intense conflicts about homosexuality and that alcohol allows
them to express these unconscious feelings in a way that is
socially acceptable.
 Rado has suggested that addicts take drugs to find relief from a
specific type of depression.
 Glover had proposed addiction as a way of expressing
aggressive and sadistic instincts.

29.  Balint characterized the alcoholics as having a basic character
flaw which he called the ‘basic fault’, and suggested that a
patients resort to alcohol as a means of correcting the fault
within himself.
Fixation:
Early psychodynamic views tended to focus on oral dependency
and libidinal drives. According to this viewpoint, children who are
fixated at oral stage ranging from 0 to 2 years of psychosexual
stages of development, as given by Freud, have more
vulnerability for substance abuse and to develop dependence.
They either try to continue the oral pleasure (in case of over
fulfillment) or to compensate the deficiency (in case of under
fulfillment) via substance abuse.

30. Recent Psychodynamics Theories:
 Weak Ego-Functions: Modern psychodynamic notion views
substance abuse as an attempt to compensate for major
deficits in ego development and affect (Khantzian,1994).Thus,
drugs are used to reduce painful emotional states or as
defense mechanism in relation to an internal conflict (Shaffer
and Jones,1985).
 Object Relation Theories: Winnicot described the object
relationship of early developmental period. The early
experiences of the child with the mother have become
increasingly important in understanding the etiology of the
addictive core of the self. Thus, psychoanalysis of the
substance has centered on stages of structural development,
including appropriate functions of the ego and a secure sense
of self. As traumatized adult, these individuals seek self
regulation outside of themselves through alcohol or other drugs
or via addictive relationships.

31.  Wieder & Kaplan emphasized that the dominant conscious
motive for substance use is reduction in distress that the
individual cannot achieve by his own psychic efforts.
 Rothschild had stated that in substance abusers, the
improvements of ego functions are typically defended against
by denial (Johnson & Muffler, 1997).
 Object Deficits In later life: Need for drug is also seen as
reflecting “object deficits” i.e., lack of gratifying relation with
others. According to this viewpoint, the substance function as
an external aid or transitional object in order for the person to
maintain a sense of well being. Thus, substance abuse is a
way to cope with the anxiety associated with intimacy i.e. lack
of emotional relationships (Hendin,1974).

32. Defense mechanisms
The perpetuating role of some of the defense mechanisms,
conscious or unconscious or partially both, in persons with
substance abuse disorders is well accepted. Some of the
common defense mechanisms of this kind have been identified
and described by workers from many perspectives. These are:
 Denial:
It is one of the commonest and the strongest defense mechanism
by which the person denies the use pattern (amount or frequency
of use), the problems associated with the use, the loss of control
over one’s use pattern and need for external help.
‘People say things about me taking drugs for no reasons.’
 Rationalization:
The person believes in and provides an apparently logical
explanation for the substance use or its pattern, based on the
circumstances and other persons around.
‘Everybody around here is into using alcohol.’

33.  Projection:
The person perceives and attributes the origin and/or
perpetuation of substance use pattern or the related problems as
emanating from some other person or source, instead of being
part of one’s own behaviour.
‘My friends always have thing for drinking.’
 Intellectualization:
Intellectualization allows us to keep from feeling emotional
connection to our behaviour. It allows us to focus on the thinking
aspects of something to deflect personal connection.
An example might be the cannabis addict who tries to divert
and deflect attention from talking about the impact of pot on his
own life by trying to engage in a debate over legalization of pot.
 Displacement:
Redirecting feelings to vulnerable substitutes.
‘After I have few joints, I forget about how much I hate
school.’

34.  Identification:
Assuming desired attributes of another person through fantasized
associations.
“I really admire his cool, and drugs are just part of it.”
 Regression:
Reverting to developmentally immature behaviour.
“What’s really wrong with getting high?”
 Reaction Formation:
Demonstrating exaggerated moralistic actions that are directly
contrary to cognitive and affective functioning.
‘Anybody who is in drug is mentally deranged.’
 Repression:
Excluding from awareness intolerable cognitions and affect.
‘I can not really recall having any problems with substance
abuse.’
 Undoing:
Nullifying a perceived transgression through a reverse action.
‘I like getting high, but I never do it.’
-Defense Mechanisms in Counselling Processes, By Arthur J Clark

35. BEHAVIORAL VIEWPOINT
Operant Conditioning
 Positive Reinforcement:
• The positive reinforcement models focus on the pleasurable,
euphoric feelings induced by drugs, alteration of mood and
posit that these powerful rewarding effects are the primary
explanation of drug use (Carroll & Bickel,1998).
• Conger(1950) showed that alcohol reinforces or enhances
positive mood and this enhancement of positive moods acts as
a reward that again increases the intake of alcohol.
 Negative Reinforcement:
• People also become negatively reinforced to use substances.
Findings of Steele & Joseph(1988) stated that alcohol may
produce its tension reducing effect by altering cognition and
perception and narrowing attention to cues related to tension
and conflict so people continue to take substances to avoid
negative moods .

36. Conditioning:
The greatest problem in substance abuse is keeping the
individuals abstinent. The conditioning model provides a
framework for understanding this aspect of substance abuse and
dependence. According to this viewpoint, drug is a non-
conditioned stimulus that becomes associated with many signals
in the user’s environment: sight, sounds, feelings, situations.
These signals become powerful conditioned stimuli through their
repeated pairing with the drug state and they may contribute to
the reinstatement of drug seeking behaviour (Wikler,1973).
Opponent-Process Theory:
The opponent process theory of acquired motivation has strongly
influenced the notion of addictive behaviour (Solomon &
Corbit,1974). The idea of opponent process is based on the
theory that systems react and adapt to stimuli by opposing their
initial effects. The same phenomenon is true for psychoactive
drugs.

37. A desire or craving for a drug, which clearly did not exist before
experience with the substance, increases with exposure to it. The
opponent-process theory attempts to explain this increased
motivation to continue drug use. It is based on three important
phenomenon:
 First, the pharmacological effects of drugs following initial
use results in a hedonic (emotional) state known as
“affective pleasure”.
 Second, with repeated exposure, “affective tolerance “
develops. Tolerance will develop to affective and euphoric
effects of the drug.
 Third, related to tolerance, the third phenomenon is
“affective withdrawal” which occurs when the drug is not
taken.

38. Psychological Vulnerability:
Is there an alcoholic personality- a type of character that
predisposes a person to use alcohol rather than adopt some
other defensive pattern of coping with stress?
In efforts to answer this question, investigators have found that
many potential alcohol abusers tend to be emotionally immature,
expect a great deal of the world, require an inordinate amount of
praise and appreciation, react to failure with marked feelings of
hurt and inferiority, have low frustration-tolerance, and feel
inadequate and unsure of their abilities to fulfil expected males or
females role. Person at high risk for developing alcohol-related
problems are significantly more impulsive and aggressive than
those at low risk for abusing alcohol (Morey & Skinner,2004).

39. Free-will Model Or "Life-process Model"
It was proposed by Thomas Szasz and later refined by Jeffrey
Schaler questions the very concept of "use or abuse." Free-will
model theorists argue that abuse cannot be a disease, because
drug-taking is a behaviour, and all behaviours are choices.
Szasz views Abuse as a metaphor, and that the only reason to
make the distinction between habit and abuse "is to persecute
somebody." Free-will model theorists believe that individuals are
capable of deliberate action in pursuit of chosen goals, and that
physiology alone can never determine whether a person will take
a drug, or how often they will take it.
The free-will model is opposed by groups like the American
Psychiatric Association (APA) and the National Institute of
Mental Health (NIMH).

40. Pleasure Model
It was proposed by professor Nils Bejerot. Abuse "is an emotional
fixation (sentiment) acquired through learning, which intermittently
or continually expresses itself in purposeful, stereotyped
behaviour with the character and force of a natural drive, aiming
at a specific pleasure or the avoidance of a specific discomfort."
"The pleasure mechanism may be stimulated in a number of ways
and give rise to a strong fixation on repetitive behaviour.
Stimulation with drugs is only one of many ways, but one of the
simplest, strongest and often also the most destructive. If the
pleasure stimulation becomes so strong that it captivates an
individual with the compulsion and force characteristic of natural
drives, then there exists...an Abuse". The pleasure model is used
as one of the reason for zero tolerance for use of illicit drugs.
Experiential Model
It was devised by Stanton Peele who argues that abuses occur
with regard to experiences generated by various involvements,
whether drug-induced or not.

41. This model is in opposition to the disease, genetic, and
neurobiological approaches. Among other things, it proposes that
abuse is both more temporary or situational than the disease
model claims, and is often outgrown through natural processes.
Allostatic Model
Allostatic (stability through change) model generated by George
Koob and Michel Le Moal is a modification of the opponent
process theory where continued use of a drug leads to a spiralling
of uncontrolled use, negative emotional states and withdrawal and
a shift into use to new allostatic set point which is lower than that
maintained before use of the drug.

42. Moral Model
It states that Abuses are the result of human weakness, and are
defects of character. Those who advance this model do not
accept that there is any biological basis for Abuse. They often
have scant sympathy for people with serious Abuses, believing
either that a person with greater moral strength could have the
force of will to break an Abuse, or that the addict demonstrated a
great moral failure in the first place by starting the Abuse. The
moral model is widely applied to dependency on illegal
substances, perhaps purely for social or political reasons, but is
no longer widely considered to have any therapeutic value.
Elements of the moral model, especially a focus on individual
choices, have found enduring roles in other approaches to the
treatment of dependencies. So, if someone drinks too much, they
do so of their own free-will, and if their drinking causes harm to
them or their family, their actions are morally bad. The corollary
attitude of this is that public drunkenness should be punished.

44. Social Control Theory:
What causes drug use, like most or all deviant behaviour, is the
absence of social controls encouraging conformity. Most of us do
not engage in deviant or criminal acts because of strong bonds
with or ties to conventional, mainstream persons, beliefs,
activities, and social institutions. If these bonds are weak or
broken, we will be released from society’s rules and free to
deviate-and this includes drug use.
Social Learning Theory:
Modelling effects begins with observation and imitation of
substance-specific behaviours, continue with social reinforcement
for and expectations of positive consequences from substance
use and culminate in substance use and misuse.
Cultural Attitudes:
Culture shapes our behaviour. So, what is considered as
acceptable behaviour in one’s culture affects one’s interest and
behaviours and so as their drinking habits. At the broadest level,
there is a cross sectional differences/ variations in substance-
abuse and dependence. De Lint(1978) found high consumption
rates typically in wine drinking societies such as France, Spain,
Italy where drinking regularly is widely accepted.

45. Thus, cultural attitudes and patterns of drinking influence the
likelihood of drinking heavily and therefore abusing.
In India, the cultural traditions and permissiveness of alcohol use
in Punjab has been seen to be associated with higher rates of
alcohol use disorders in epidemiological studies where as
Gujarat being dry state has been shown to be associated with
lower rates of alcohol use disorders.
Family:
Family variables are also important socio-cultural influences. If
both parents smoke, a child is four times more likely to do so.
Cloninger et.al 1981 found exposures to alcohol use by parents
increases child’s likelihood of drinking. Psychiatric, marital or
legal problem in the family and lack of emotional support from
family, cohesion, expressiveness, independence and intellectual
cultural orientation are also related to substance abuse.

46. Social Milieus:
The social milieu, in which a person operates can also affect
substance abuse. Richardson et.al found tobacco use among
high school students is highest in identifiable sub-groups: those
with poor grades, behaviour problems and taste of heavy metal
music, and found peer group identification as a major cause
behind abuse. Thus, peers influences are important in promoting
substance abuse.
Media:
Media is an another variable in this context. We are bombarded
with TV commercials in which beer or substance abuse is
equated with excitement, relaxation or being in style.
Shaffer(1991) in his analysis found that those countries that
banned advertisements for spirits had 16% less consumptions
than those did not.

47. Conclusion
“Drugs take you to hell, disguised as heaven”
One does not usually intend to become an addict or abuse
substance and no one wakes up one morning and decide
to be a drug addict in first place. Substance abuse is a
burning problem in which not only the victims but their
family members also go through a great toil. There are
numerous reasons and circumstances in which a person
switch to substance abuse . As mental health
professionals, we should keep in our mind those various
reasons which compels one to abuse or become an addict.
If the aim is to ameliorate the suffering of the victim and to
decrease the burden of their family members, we need to
decide onto the most appropriate treatment , we must take
into consideration all the possible reasons that leads to the
abuse and try to cut them down for a successful and fruitful
treatment.

48. Contact information:
Ms. Deepanwita Roy
Clinical Psychologist (RCI Registered)
Email address: deepanwitaroycp@gmail.com