Chapter 10 Substance Related Disorders

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

2. 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 % Based on substance 2 Percentage of Indonesian Population Reporting Drug Use in 2003-2006 (Based on BNN survey) Based on areas

3. 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. Abuse 3 Substance Dependence and Abuse Dependence ( Adiction)

4. 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 Alcohol Dependence and Abuse 4

5. 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 5 Alcohol Abuse and Dependence

6. 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 6 Alcohol Abuse and Dependence

7. 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 7 Prevalence of Alcohol Abuse

8. 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 8 Short-term Effects of Alcohol

9. 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 9 Short-term Effects of Alcohol

10. 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 10 Long-term Effects of Alcohol

11. 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 11 Fetal Alcohol Syndrome

12. 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 Nicotine and Cigarette Smoking 12

13. 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 13 Prevalence and Health Consequences

14. 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 Marijuana 14

15. 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 15 Prevalence

16. 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 16 Effects of Marijuana

17. 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 17 Therapeutic Effects of Marijuana

18. 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. Opiates 18

19. 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 19 Prevalence of Opiate Use

20. 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 20 Psychological and Physical Effects of Opiates

21. 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 21 Psychological and Physical Effects of Opiates

22. 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 Synthetic Sedatives 22

23. 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) Stimulants: Amphetamines 23

24. 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) 24 Stimulants: Methamphetamine

25. 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). Stimulants: Cocaine 25

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

27. 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 Hallucinogens, Ecstasy, and PCP 27

28. 28 Figure 10.5 Process of Becoming a Drug Abuser

29. 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 29 Etiology of Substance-Related Disorders: Developmental approach

30. 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) 30 Etiology of Substance-Related Disorders:Genetic Factors

31. 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. 31 Etiology of Substance-Related Disorders: Neurobiological Factors

32. 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 32 Etiology of Substance-Related Disorders: Psychological factors

33. 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. 33 Etiology of Substance-Related Disorders: Psychopathology and Personality

34. 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 34 Etiology of Substance-Related Disorders: Sociocultural factors

35. 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) 35 Etiology of Substance-Related Disorders: Sociocultural factors

36. 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) 36 Etiology of Substance-Related Disorders: Sociocultural factors

37. 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. Treatment of Substance Related Disorders: Alcohol Abuse and Dependence 37

38. 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 Treatment of Substance Related Disorders: Alcohol Abuse and Dependence 38

39. 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 Treatment of Substance Related Disorders: Alcohol Abuse and Dependence 39

40. 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 Treatment of Substance Related Disorders: Alcohol Abuse and Dependence 40

41. 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 Treatment of Substance Related Disorders: Nicotine Dependence 41

42. 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 Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence 42

43. 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) Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence 43

44. 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 Prevention of Substance-Related Disorders 44