Guide
Guide | Reference

23  Substance Use and Compulsive Reward Seeking

23.1 Summary

  • Compulsive use of substances or reward-seeking behaviors despite negative consequences and loss of control.

23.2 Patient-Language Phrases

  • “I keep using even when I tell myself I won’t.”
  • “I need more to get the same effect.”
  • “I feel sick or anxious if I stop.”
  • “It’s the only thing that helps me feel okay.”

23.3 Core Features

  • Craving or compulsive use.
  • Loss of control over quantity or frequency.
  • Tolerance and withdrawal patterns.
  • Continued use despite harm.

23.4 Boundary Markers

  • What it is: persistent, harmful use with impaired control.
  • What it is not: occasional use without loss of control or harm.

23.5 Quick Structure

  • Variants / Spectrum
    • Binge or episodic use patterns.
    • Daily or steady use patterns.
    • Polysubstance use.
    • Behavioral reward seeking (evidence-graded).
  • Severity (0-4)
    • 0: No clinically meaningful compulsive use.
    • 1: Mild, intermittent, limited consequences.
    • 2: Moderate, recurring, with clear impairment.
    • 3: Severe, persistent, with significant harm.
    • 4: Extreme, disabling or unsafe.
  • Time-course
    • Episodic with relapse cycles.
    • Chronic, persistent use.
    • Fluctuating with stress or access.
  • Functional impact
    • Work/school: missed obligations, decreased performance.
    • Relationships: conflict, secrecy, isolation.
    • Self-care: health decline, risk behaviors.
  • Developmental expression
    • Adolescence: risk-taking, peer-influenced use.
    • Adulthood: coping-related or dependence patterns.
    • Late life: medication interactions and misuse.
  • Cultural/context notes
    • Use patterns shaped by access, norms, and legal context.
    • Stigma can distort reporting.