Chapter 10 Substance Related Disorders

1. Chapter 10 Substance Related Disorders Abnormal Psychology, Eleventh EditionbyAnn M. Kring, Gerald C. Davison, John M. Neale, & Sheri L. Johnson

2. Percentage of Indonesian Population Reporting Drug Use in 2003-2006 (Based on BNN survey) Based on areas Based on substance • Jakarta : 23% • Medan : 15% • Bandung : 14% • Surabaya : 6.3 % • Maluku utara : 4.3 % • Padang : 5.5 % • Kendari : 5% • Marijuana : 74.9 % • Anti-Depressant : 32.5 % • Ecstasy : 25.7 % • Amphetamine : 21.5 %

3. Substance Dependence and Abuse Dependence ( Adiction) Abuse • Occupational or social problems, much time trying to obtain substance, continued use despite problems, etc. • Involves either tolerance or withdrawal • Tolerance • Greater amounts required to produce desired effect • Withdrawal • Physiological and psychological consequences when individual discontinues or reduces substance use • Restlessness, anxiety, cramps, death • Maladaptive use of substance • No physiological dependence • In 2006, 22 million met criteria for dependence or abuse. • Of those 15 million involved alcohol.

4. Alcohol Dependence and Abuse • Alcohol abuse • Negative social and occupational effects • No tolerance, withdrawal, or compulsive usage • Alcohol Dependence • More severe symptoms such as tolerance and withdrawal • Withdrawal results in: • Anxiety • Depression • Weakness • Restlessness • Insomnia • Muscle tremors • Face, fingers, eyelids, other small musculature • Elevated BP, pulse, temperature

5. Alcohol Abuse and Dependence • Delirium tremens (DTs) • Can occur when blood alcohol levels drop suddenly • Results in: • Deliriousness • Tremulousness • Hallucinations • Primarily visual; may be tactile • 2.5% of alcohol abusers develop dependence

6. Alcohol Abuse and Dependence • Polydrug abuse • Many users abuse multiple substances • e.g., cigarettes, cocaine, marijuana • 85% of alcohol are smokers • Synergistic • Some combinations of drugs produce stronger reaction • Alcohol and barbiturates • May cause death • Alcohol and heroin • Alcohol reduces amount of heroin needed to produce lethal dose

7. Prevalence of Alcohol Abuse • Lifetime prevalence (Kessler et al., 1994) • 20% for men • 8% for women • Lifetime prevalence: • Abuse - 17% • Dependence – 12% • Binge drinking • 5 drinks in short period • 43.5% prevalence among college students • Heavyuse drinking • 5 drinks, 5 or more times in a 30 day period • 17.6% prevalence among college students

8. Short-term Effects of Alcohol • Enters the bloodstream through small intestine • metabolized by the liver • Effects vary by concentration • Concentration varies by gender, height, weight, liver efficiency Affects brain areas associated with error monitoring and decision making. • Biphasic effect • Initially stimulates • Later depresses

9. Short-term Effects of Alcohol • Effect of ingesting large amounts • Impaired speech and vision • Interference in complex thought processes • Poor coordination • Loss of balance • Depression and withdrawal • Interacts with several neural systems • Stimulates GABA receptors • Increases dopamine and serotonin • Inhibits glutamate receptors

10. Long-term Effects of Alcohol • Malnutrition • Alcohol interferes with digestion and absorption of vitamins from food • Deficiency of B-complex vitamins • Amnestic syndrome • Severe loss of memory for both long and short term information • Cirrhosis of the liver • Liver cells engorged with fat and protein impeding functioning • Cells die triggering scar tissue which obstructs blood flow • Damage to endocrine glands and pancreas • Heart failure • Erectile dysfunction • Hypertension • Stroke • Capillary hemorrhages • Facial swelling and redness, especially in nose • Destruction of brain cells • Especially areas important to memory

11. Fetal Alcohol Syndrome • Heavy alcohol intake during pregnancy • Fetal growth slowed • Cranial, facial and limb anomalies occur • Moderate alcohol intake • 1 drink per day • Learning and memory impairments • Growth deficits • Total abstinence recommended by NIAAA

12. Nicotine and Cigarette Smoking • Nicotine • Addicting agent of tobacco • Principal alkaloid • Active chemicals that give drugs their physiological and psychological altering properties • Stimulates dopamine neurons in mesolimbic area • Involved in reinforcing effect

13. Prevalence and Health Consequences • Prevalence decreased since mid 1960s although use increased through the 1990s, among white adolescents • More prevalent among white & Hispanic youth than African Americans • African Americans less likely to quit and more likely to get lung cancer • Metabolize nicotine more slowly • Chinese Americans have lower lung cancer rates • Metabolize less nicotine • More prevalent among men than women • Exception: 12 to 17 year olds • Secondhand smoke (ETS, environmental tobacco smoke) • Higher levels of ammonia, carbon monoxide nicotine and tar • Causes 40,000 deaths per year in US

14. Marijuana • Drug derived from dried and ground leaves and stems of the female hemp plant (Cannibis sativa) • Hashish • Stronger than marijuana • Produced by drying the resin exudate of the tops of plants

15. Prevalence • Most frequently used illicit drug in US • 15,000,000 reported using it in 2006 • Peaked in 1979 then began to decline • Rose again in 90s • Greater use by men than women although rates among women increased faster in 1990s

16. Effects of Marijuana • Major active ingredient • THC (delta-9-tetrahydrocannabinol) • Psychological • Feelings of relaxation and sociability • Rapid shifts of emotion • Interferes with attention, memory, and thinking • Decline in IQ over time • Heavy doses can induce hallucinations and panic • Impairment of skills needed for driving • Impairment present for several hours after ‘high’ has worn off • Physiological • Bloodshot & itchy eyes • Dry mouth and throat • Increased appetite • Reduced pressure within the eye • Increased BP • Abnormal heart rate • May exacerbate preexisting cardiovascular problems • Damage to lung structure and function in long term users

17. Therapeutic Effects of Marijuana • Reduces nausea and loss of appetite caused by chemotherapy (Salan et al., 1975) • Relieves discomfort of AIDS (Sussman et al., 1996) • Analgesic effects due to ability of THC to block pain signals from reaching the brain. • Supreme Court rulings: • Federal law prohibits dispensing marijuana for medicinal purposes • Medical use can be prohibited by federal government even if states approve

18. Opiates • Group of addictive sedatives that in moderate doses relieve pain and induce sleep • Opium • Morphine • Heroin • Codeine • Synthetic sedatives • Seconal and valium • Opiates legally prescribed as pain medications include: • Hydrocodone combined with other substances yields Vicodin, Zydone, and Lortab • Oxycodone the basis for OxyContin, Percodan, & Tylox.

19. Prevalence of Opiate Use • Heroin • Estimated1,000,000 individuals addicted to heroin in US • 300,000 in 2006 alone • From 1995 to 2002, rates of use among adults 18 to 25 increased from 0.8% to 1.6% • Accounted for 62 to 82% of drug-related hospital admissions in Baltimore, Boston, & Newark. • Heroin is more pure (25 to 50%) than in the past • Increases likelihood of overdose • OxyContin prescriptions jumped 1800% between 1996 and 2000 (DEA, 2001) • 2.8 million users (SAMSHA, 2004) • Can be dissolved for injection or snorting • Street price from $25 to $40 per pill

20. Psychological and Physical Effects of Opiates • Euphoria, drowsiness, reverie, and lack of coordination • Loss of inhibition, increased self-confidence • Severe letdown after about 4 to 6 hours • Heroin and OxyContin • Rush • Intense feelings of warmth and ecstasy following injection • Stimulate receptors of the body’s opioid system • Endorphins and enkephalins • Tolerance develops and withdrawal occurs • Muscle soreness and twitching, tearfulness, yawning • Become more severe and also include cramps, chills/sweating, increase in HR and BP, insomnia, & vomiting • Withdrawal lasts about 72 hours

21. Psychological and Physical Effects of Opiates • 29 year follow up of 500 heroin addicts (Hser, et al., 1993) • 28% dead by age 40 • Half by suicide, homicide, or accident • One-third by overdose • Many users resort to illegal activities to obtain money for drugs • Theft, prostitution, dealing drugs • Exposure to infectious diseases via shared needles • e.g. HIV • Evidence suggests that free needles reduces infectious diseases associated with IV drug use

22. Synthetic Sedatives • Barbituates • Induce muscle relaxation, reduce anxiety, produce mild euphoria • In 1940s prescribed to aid sleep • Usage declined from 1975 thru 1990s but increased recently • Other synthetic sedatives • Benzodiazepines • e.g., Valium, Ketamine • Stimulate GABA system • Heavy dosages • Slurred speech • Unsteady gait • Impaired judgment & concentration • Irritability & combativeness • Accidental suffocation due to excessive relaxation of diaphragm muscles • Alcohol magnifies depressant effects • Tolerance & withdrawal • Delirium, convulsions & other symptoms

23. Stimulants: Amphetamines • Increase alertness and motor activity • Reduce fatigue • Amphetamines • Synthetic stimulants • Benzedrine, Dexedrine, Methedrine • Trigger release of and block reuptake of norepinephrine and dopamine • Produce high levels of energy, sleeplessness • Reduce appetite, increase HR, constrict blood vessels in skin and mucous membranes • High doses can lead to: • Nervousness, agitation, irritability confusion, paranoia, hostility • Tolerance can develop after only 6 days use (Comer et al., 2001)

24. Stimulants: Methamphetamine • Amphetamine derivative (aka crystal meth) • Can be taken orally, intravenously, or intranasally (snorting) • In 2006, over 700,000 people used methamphetamine (SAMHSA, 2007). • Chronic use damages brain • Reduction in hippocampus volume (see figure 10.4; abusers represented by yellow bars)

25. Stimulants: Cocaine • Alkaloid obtained from coca leaves • Reduces pain • Produces euphoria • Heightens sexual desire • Increases self-confidence and indefatigability • Blocks reuptake of dopamine in mesolimbic areas of brain • Overdose • Chills, nausea, insomnia, paranoia, hallucinations; possibly heart attack & death • Not all users develop tolerance • Some become more sensitive • May increase risk of OD • In 2006, 2.4 million people over the age of 12 reported using cocaine, and 700,000 reported using crack (SAMHSA, 2007).

26. Stimulants: Cocaine • Crack • Form of cocaine that quickly become popular in the 80s • Rock crystal that is heated, melted, & smoked • Cheaper than cocaine

27. Hallucinogens, Ecstasy, and PCP • Hallucinogeneffects include: • Colorful visual hallucinations • Synestesias • Overflow from one sensory modality to another • Alterations in time perception • Lability of mood • Anxiety & paranoia • LSD • d-lysergic acid diethylamide • Psilocybin • Extracted from mushroom psylocube mexicana • Mescaline • Active ingredient of peyote • Ecstasy • Increase feelings of intimacy and enhances mood • Chemically similar to mescaline and amphetamines • PCP (phencyclidine) • Angel dust • Animal tranquilizer • Causes severe paranoia and violence

28. Figure 10.5 Process of Becoming a Drug Abuser

29. Etiology of Substance-Related Disorders: Developmental approach • Li et al. (2001) Two paths to alcohol abuse • First group began drinking in early adolescence, increased drinking throughout high school • Second group drank lesser amounts in early adolescence, increased drinking in middle school and again in high school. • Boys more likely to be in the first group, girls in the second group • Developmental studies do not account for all cases • Not an inevitable progression through stages

30. Etiology of Substance-Related Disorders:Genetic Factors • Relatives and children of problem drinkers have higher-than-expected rates of alcohol abuse or dependence • Greater concordance in MZ than DZ twins • In men • Alcohol, caffeine, smoking, marijuana, & drug abuse in general • In women • Role of genetics less clear • Fewer available studies • Findings are mixed • Genetic and shared environmental risk factors for illicit drug abuse and dependence appear to be nonspecific • Ability to tolerate large quantities of alcohol may be an inherited diathesis • Asians have low rates of alcohol abuse • CYP2A6 • Gene associated with metabolism of nicotine • Smokers with defect in this gene less likely to become dependent (Rao et al., 2000)

31. Etiology of Substance-Related Disorders: Neurobiological Factors • Nearly all drugs, including alcohol, stimulate the dopamine system in the brain • Some evidence that people dependent on drugs or alcohol have a deficiency in the dopamine receptor DRD2 • People take drugs to avoid the bad feelings associated with withdrawal • Explains frequency of relapse • Incentive-sensitization theory (Robinson & Berridge, 19983, 2003) • Distinguish • Wanting (craving for drug) • Liking (pleasure obtained by taking the drug) • Dopamine system becomes sensitive to the drug and the cues associated with drug (e.g., needles, rolling papers, etc.) • Sensitivity to cues induces & strengthens wanting • Brain imaging studies show that cues for a drug (needle or a cigarette) activate the reward and pleasure areas of the brain involved in drug use.

32. Etiology of Substance-Related Disorders: Psychological factors • Mood alteration • Tension reduction may be due to “alcohol myopia” (Steele & Joseph, 1990) • User focuses reduced cognitive capacity on immediate distractions • Less attention focused on tension-producing thoughts • Effect similar for smoking • Cognitive distraction also reduces aggressive behavior in intoxicated individuals • However, alcohol and nicotine may increase tension when no distractions are present. • Expectancies about drugs effects influence behavior • People who expect alcohol to reduce stress & anxiety are most likely to drink • The greater perceived risk, the less likely it is to be used

33. Etiology of Substance-Related Disorders: Psychopathology and Personality • Personality factors that predict onset of substance related disorders: • Negative emotionality • Desire for increased arousal and positive affect • Constraint • Harm avoidance, conservative moral values, & cautious behavior • Kindergarten children who were rated high in anxiety and novelty seeking more likely to get drunk, smoke, and use drugs in adolescence.

34. Etiology of Substance-Related Disorders: Sociocultural factors • Alcohol is the most common abused substance worldwide (Smart & Ogborne, 2000) • Men consume more alcohol than women but differences vary by country • Israel • Men drank 3x as much as women • Netherlands • Men drank 1½x as much as women • Availability • Usage is higher when alcohol and drugs are easily available

35. Etiology of Substance-Related Disorders: Sociocultural factors • Family factors • Parental alcohol use (Hawkins et al., 1997) • Psychiatric, marital, or legal problems in the family linked to drug abuse • Lack of emotional support from parents increases use of cigarettes, marijuana, and alcohol (Cadoret et la., 1995a) • Lack of parental monitoring linked to higher drug usage (Chassin et al., 1996; Thomas et al., 2000)

36. Etiology of Substance-Related Disorders: Sociocultural factors • Social network • Social influence or social selection? • Bullers et al.(2001) found evidence for both • Having peers who drink influences drinking behavior (social influence) but individuals also choose friends with drinking patterns similar to their own (social selection) • Advertising and Media • Countries that ban ads have 16% less consumption than those that don’t (Saffer, 1991)

37. Treatment of Substance Related Disorders: Alcohol Abuse and Dependence • Inpatient hospital treatment • Detoxification • Withdrawal from alcohol under medical supervision • The therapeutic results of hospital treatment are not superior to those of outpatient treatment • Alcoholics Anonymous (AA) • Largest self-help group for problem drinkers • Regular meetings provide support, understanding, and acceptance • Promotes complete abstinence • Although some studies have shown AA participation predicts better outcome, recent studies suggest AA no more effective than other forms of therapy.

38. Treatment of Substance Related Disorders: Alcohol Abuse and Dependence • Couples and Family Therapy • Emphasizes support from problem drinker’s partner • Reduced problem drinking maintained1 year after therapy ended • Also reduced couples’ overall level of distress

39. Treatment of Substance Related Disorders: Alcohol Abuse and Dependence • Cognitive and Behavioral Treatments • Contingency-Management Therapy • Patient and family reinforce behaviors inconsistent with drinking • e.g., avoiding places associated with drinking • Teach problem drinker how to deal with uncomfortable situations • e.g., refusing the offer of a drink • AKA Community-reinforcement approach • Relapse Prevention • Strategies to prevent relapse • Brief motivational interventions • Designed to curb heavy drinking in college

40. Treatment of Substance Related Disorders: Alcohol Abuse and Dependence • Controlled drinking • Belief that problem drinkers can consume alcohol in moderation • Avoid total abstinence and inebriation • Guided self-change • Medications • Antabuse (disulfiram) • Produces nausea and vomiting if alcohol is consumed • Other medications include naltrexone, naloxone, & acamprosate • Most effective when combined with CBT

41. Treatment of Substance Related Disorders: Nicotine Dependence • Peer behavior important • If others in social network stop smoking, increases likelihood that individual will also stop • Rapid smoking treatment • Rapid puffing, focused smoking, & smoke holding • Scheduled smoking • Reduce nicotine intake gradually over a few weeks • Physician’s advice • By age 65, most smokers have quit (USDHHS, 1998b) • Nicotine replacement treatments • Gum, patches, or inhalers • Reduce craving for nicotine • Combining patch with antidepressants improved success rate

42. Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence • Detoxification central to treatment • Psychological treatments • Desipramine and CBT showed effectiveness for cocaine use • CBT especially helpful for users with high dependence levels (Carroll et al., 1994, 1995) • Operant conditioning • Tokens that can be traded for desirable goods are given to users who abstain (Dallery et al., 2001) • Motivational interviewing or enhancement thereapy • CBT plus Rogerian therapy effective for alcohol and drug use (Burke et al., 2003) • Self-help residential homes for heroin users • Non-drug environment • Group therapy • Guidance and support from former users

43. Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence • Drug replacement treatments and medications • A meta-analysis of stimulant medication as a treatment for cocaine abuse revealed little evidence that this type of medication is effective • Heroin replacements • Synthetic narcotics • Methadone, levomethadyl acetate, bupreophine • Used to wean heroin users from dependence • More effective if combined with psychological support & treatment (Lilley et al., 2000)

44. Prevention of Substance-Related Disorders • Often aimed at adolescents • Utilize some or all of the following elements: • Enhancing self-esteem • Social skills training • Peer pressure resistance training • Parental involvement in school programs • Warning labels on alcohol bottles • Education regarding alcohol impairment • Testing for drugs and alcohol at school or work