Reference
Guide | Reference

33  Substance Use and Compulsive Reward Seeking

33.1 Summary

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

33.2 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.”

33.3 Core Features

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

33.4 Boundary Markers

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

33.5 Variants / Spectrum

  • Binge or episodic use patterns.
  • Daily or steady use patterns.
  • Polysubstance use.
  • Behavioral reward seeking (evidence-graded).

33.6 Severity Anchors (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.

33.7 Time-Course Patterns

  • Episodic with relapse cycles.
  • Chronic, persistent use.
  • Fluctuating with stress or access.

33.8 Functional Impact

  • Work/school: missed obligations, decreased performance.
  • Relationships: conflict, secrecy, isolation.
  • Self-care: health decline, risk behaviors.

33.9 Common Mimics / Differential

  • Primary mood or anxiety symptoms driving use.
  • Medical conditions with overlapping symptoms.

33.10 Medical / Substance Rule-Outs

  • Intoxication or withdrawal states.
  • Medication interactions or iatrogenic effects.

33.11 Developmental Expression

  • Adolescence: risk-taking, peer-influenced use.
  • Adulthood: coping-related or dependence patterns.
  • Late life: medication interactions and misuse.

33.12 Cultural / Context Notes

  • Use patterns shaped by access, norms, and legal context.
  • Stigma can distort reporting.

33.13 Measurement Prompts

  • Brief substance use screen.
  • Timeline of use and consequences.

33.15 Documentation Snippet (1-2 lines)

  • “Reports compulsive alcohol use with craving and withdrawal; Reward/Habit 3; chronic course.”