Chapter 11 Substance-Related and Impulse-Control Disorders

1. Chapter 11Substance-Related and Impulse-Control Disorders

2. Perspectives on Substance-RelatedDisorders: An Overview • The Nature of Substance-Related Disorders • Use and abuse of psychoactive substances • Wide-ranging psychophysiological and behavioral effects • Associated with significant impairment and costs • Some Important Terms and Distinctions • Substance use vs. substance intoxication • Substance abuse vs. substance dependence • Tolerance vs. withdrawal

3. Perspectives on Substance-RelatedDisorders: An Overview (cont.) • Five Main Categories of Substances • Depressants – Result in behavioral sedation • Stimulants – Increase alertness and elevate mood • Opiates – Primarily produce analgesia and euphoria • Hallucinogens – Alter sensory perception • Other drugs of abuse – Include inhalants, anabolic steroids, medications

4. The Depressants: Alcohol Use Disorders • Psychological and Physiological Effects of Alcohol • Central Nervous system depressant • Affects several neurotransmitter systems • Specific target is GABA • Effects of Chronic Alcohol Use • Alcohol intoxication & withdrawal • Associated conditions – Dementia & Wernicke’s disease • Fetal alcohol syndrome • DSM-IV-TR Criteria for Disordered Alcohol Use

5. Alcohol: Some Facts and Statistics • In the United States • Most adults view themselves light drinkers or abstainers • Over 50% of the U.S. (> 12 years age) report current use • 15 million Americans are alcohol dependent • Rates are highest among Caucasian & Native Americans • Males use and abuse alcohol more than females • Violence is associated with alcohol • Alcohol alone does not cause aggression

6. Sedative, Hypnotic, or AnxiolyticSubstance use Disorders: An Overview • The Nature of Drugs in This Class • Sedatives – Calming (e.g., barbiturates) • Hypnotic – Sleep inducing • Anxiolytic – Anxiety reducing (e.g., benzodiazepines) • Effects Are Similar to Large Doses of Alcohol • Combining such drugs with alcohol is synergistic • All Influence the GABA Neurotransmitter System • DSM-IV-TR Criteria for this Class of Disorders • Main criteria and distinguishing features

7. Stimulants: An Overview • Nature of Stimulants • Most widely consumed drug in the United States • Such drugs increase alertness and increase energy • Examples include amphetamines, cocaine, nicotine, and caffeine

8. Stimulants: Amphetamine Use Disorders • Effects of Amphetamines • Produce elation, vigor, reduce fatigue • Effects are followed by extreme fatigue and depression • DSM-IV-TR Criteria for Amphetamine Intoxication • Ecstasy and Ice • Produces effects similar to speed, but no “comedown” • 2% of college students report using Ecstasy • Both drugs can result in dependence • Amphetamines stimulate CNS by • Enhancing release of norepinephrine and dopamine • Reuptake is subsequently blocked

9. Stimulants: Cocaine Use Disorders • Effects of Cocaine • Short lived sensations of elation, vigor, reduce fatigue • Blocks reuptake of dopamine • Highly addictive, but addiction develops slowly • DSM-IV-TR Criteria for Cocaine Intoxication and Withdrawal • Psychological symptoms • Physiological symptoms • Most Cycle Through Patterns of Tolerance and Withdrawal

10. Stimulants: Nicotine Use Disorders • Effects of Nicotine • Stimulates nicotinic acetylcholine receptors • Results in sensations of relaxation, wellness, pleasure • Nicotine is highly addictive • Relapse rates equal those for alcohol and heroin users • DSM-IV-TR Criteria for Nicotine Withdrawal Only • Psychological symptoms • Physiological symptoms • Nicotine Users Dose Themselves • Maintain a steady level of nicotine in the Bloodstream • Examples include smoking before sleep or after waking

11. Stimulants: Caffeine Use Disorders • Effects of Caffeine – The “Gentle” Stimulant • Found in tea, coffee, cola drinks, and cocoa products • Blocks the reuptake of the neurotransmitter adenosine • Small doses elevate mood and reduce fatigue • Used by over 90% of Americans • Regular use can result in tolerance and dependence • DSM-IV-TR Criteria for Caffeine Intoxication • Psychological symptoms • Physiological symptoms

12. Opioids: An Overview • The Nature of Opiates and Opioids • Opiate – Narcotic like chemical in the opium poppy • Opioids – Substances that produce narcotic effects • Often referred to as analgesics (i.e., help relieve pain) • Examples include heroin, opium, codeine, and morphine • Effects of Opioids • Activate body’s enkephalins and endorphins • Low doses – Euphoria, drowsiness, and slow breathing • High doses can be fatal • Withdrawal symptoms can be lasting and severe

13. Opioids: Diagnostic Criteria and Associated Features • DSM-IV-TR Criteria for Opioid Intoxication and Withdrawal • Psychological symptoms • Physiological symptoms • Mortality rates are high for opioid addicts • Users at increased risk for HIV infection

14. Hallucinogens: An Overview • Nature of Hallucinogens • Substances that alter perceptions of the world • Produce delusions, paranoia, hallucinations, and/or altered sensory perception • Examples include marijuana, LSD • Marijuana • Active chemical is tetrahydrocannabinol (THC) • Symptoms – Mood swings, paranoia, hallucinations • Impairment in motivation is not uncommon • Withdrawal and dependence are uncommon

15. Hallucinogens: An Overview (cont.) • LSD and Other Hallucinogens • LSD is most common form of hallucinogenic drug • Tolerance tends to be rapid • Withdrawal symptoms are uncommon • Can produce psychotic delusions & hallucinations • DSM-IV-TR Criteria • Marijuana and Hallucinogen Intoxication • Psychological and physiological symptoms are similar

16. Other Drugs of Abuse: Inhalants • Nature of Inhalants • Found in volatile solvents • Breathed into the lungs directly • Examples include spray paint, hair spray, paint thinner, gasoline, nitrous oxide • Such drugs are rapidly absorbed • Effects similar to alcohol intoxication • Produce tolerance and prolonged withdrawal symptoms • DSM-IV-TR Criteria for Inhalant Intoxication

17. Other Drugs of Abuse: Anabolic Steroids • Nature of Anabolic-Androgenic Steroids • Steroids are derived or synthesized from testosterone • Used medicinally or to increase body mass • Users may engage in cycling or stacking • Steroids do not produce a high • Long-term mood disturbances and physical problems

18. Other Drugs of Abuse: Designer Drugs • Designer Drugs • Drugs produced by pharmaceutical companies for diseases • Ecstasy, MDEA (“eve”), BDMPEA (“nexus”), ketamine (“special K”) are examples • All heighten auditory and visual perception (taste and touch) • Popular in nightclubs, raves, or large social gatherings • All designer drugs can produce tolerance and dependence

19. Causes of Substance-Related Disorders: Family and Genetic Influences • Results of Family, Twin, and Adoption Studies • Substance abuse has a genetic component • Much of the focus has been on alcoholism • Genetic differences in alcohol metabolism • Multiple genes are involved in substance abuse

20. Causes of Substance-Related Disorders:Neurobiological Influences • Results of Neurobiological Research • Drugs affect the pleasure or reward centers in the brain • The pleasure center – Dopamine, midbrain, frontal cortex • GABA turns off reward-pleasure system • Inhibition of neurotransmitters for anxiety / negative affect

21. Causes of Substance-Related Disorders:Psychological Dimensions • Role of Positive and Negative Reinforcement • The self-medication and the tension reduction hypotheses • Substance abuse as a means to cope with negative affect • Opponent-Process Theory • Why the crash after drug use fails to stop drug use • Role of Expectancy Effects • Expectancies influence drug use and relapse

22. Causes of Substance-Related Disorders:Social and Cultural Dimensions • Exposure to Drugs is a Prerequisite for Use of Drugs • Media, family, peers • Parents and the family appear critical • Societal Views About Drug Abuse • Sign of moral weakness – Failure of self-control • Sign of a disease – Caused by underlying processes • The Role of Cultural Factors • Influence the manifestation of substance abuse

23. An Integrative Model of Substance-Related Disorders • Exposure or Access to a Drug • Is necessary, but not sufficient for abuse and addiction • Drug Use Depends on Social and Cultural Expectations • Drugs Are Used Because of their Pleasurable Effects • Drugs Are Abused for Reasons that are More Complex • The premise of equifinality • Stress may interact with psychological, genetic, social, and learning factors

24. Figure 11.11 An integrative model of substance-related disorders.

25. Biological Treatment of Substance-Related Disorders • Agonist Substitution • Substitute safer drug with a similar chemical composition • Examples include methadone and nicotine gum or patch • Antagonistic Treatment • Drugs that block or counteract pleasurable drug effects • Examples include naltrexone for opiate and alcohol problems

26. Biological Treatment ofSubstance-Related Disorders (cont.) • Aversive Treatment • Drugs that make use of drugs extremely unpleasant • Examples include Antabuse for alcoholism and silver nitrate for nicotine addiction • Efficacy of Biological Treatment • Generally ineffective when used alone

27. Psychosocial Treatment of Substance-Related Disorders • Inpatient vs. Outpatient Care • Overall efficacy is comparable • Controlled Use vs. Complete Abstinence as Treatment Goals • Community Support Programs • Alcoholics Anonymous and related groups • Seem helpful and are strongly encouraged

28. Psychosocial Treatment ofSubstance-Related Disorders (cont.) • Comprehensive Treatment and Prevention Programs • Individual and group therapy • Aversion therapy and convert sensitization • Contingency management • Community reinforcement • Relapse prevention • Preventative efforts via education

29. Summary of Substance-Related Disorders • DSM-IV and DSM-IV-TR Substance Related Disorders • Cover four classes • Depressants, stimulants, opiates, and hallucinogens • Diagnoses include dependence, abuse, intoxication, or withdrawal • Most Activate the Dopaminergic Pleasure Pathway • Psychosocial factors interact with biological influences to produce substance disorders • Treatment of Substance Dependence • Largely unsuccessful – Highly motivated persons do well • Important to use a comprehensive treatment approach

30. Impulse-Control Disorders • DSM-IV-TR • Intermittent explosive disorder • Kleptomania • Pyromania • Pathological gambling • Trichotillomania • Each is Characterized by the Following • Increased tension/anxiety prior to the act • A sense of relief following the act • Impairment of social and occupational functioning

31. Impulse-control Disorders (cont’d.) • Intermittent Explosive Disorder • Rare condition • Characterized by frequent aggressive outbursts • Leads to injury and/or destruction of property • Few controlled treatment studies exist • Kleptomania • Failure to resist urge to steal unnecessary items • Seems rare, but it is not well studied • Highly comorbid with mood disorders • Also co-occurs with substance-related problems

32. Impulse-control Disorders (cont’d.) • Pyromania • Involves having an irresistible urge to set fires • Diagnosed in less than 4% of arsonists • Little etiological and treatment research • Pathological Gambling • Estimated to affect 3-5% adult Americans • Treatment is similar to that for substance dependence • Treatment studies are currently underway • Trichotillomania • Inability to resist the urge to pull hair • Observed in 1-5% of college students, mostly female • Clomipramine and CBT have been shown to be helpful