Chapter 10 Substance Related Disorders Abnormal Psychology Eleventh

+ Chapter 10 Substance Related Disorders Abnormal Psychology, Eleventh Edition by Ann 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 n Jakarta : 23% n Medan : 15% n Bandung : 14% n Surabaya : 6. 3 % n Maluku utara : 4. 3 % n Padang : 5. 5 % n Kendari : 5% Based on substance n Marijuana : 74. 9 % n Anti-Depressant n Ecstasy : 32. 5 % : 25. 7 % n Amphetamine : 21. 5 %

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

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

+ 5 Alcohol Abuse and Dependence n Delirium tremens (DTs) n Can occur when blood alcohol levels drop suddenly n Results in: Deliriousness n Tremulousness n Hallucinations n n Primarily visual; may be tactile n 2. 5% of alcohol abusers develop dependence

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

+ 7 Prevalence of Alcohol Abuse n Lifetime prevalence (Kessler et al. , 1994) n Lifetime prevalence: n n 20% for men 8% for women Abuse - 17% Dependence – 12% n Binge n n drinking 5 drinks in short period 43. 5% prevalence among college students n Heavy use drinking n 5 drinks, 5 or more n times in a 30 day period 17. 6% prevalence among college students

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

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

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

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

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

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

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

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

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

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

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

+ 19 Prevalence of Opiate Use n Heroin n Estimated 1, 000 individuals addicted to heroin in US n n n 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. n Heroin n is more pure (25 to 50%) than in the past Increases likelihood of overdose n Oxy. Contin prescriptions jumped 1800% between 1996 and 2000 (DEA, 2001) n 2. 8 million users (SAMSHA, 2004) n n Can be dissolved for injection or snorting Street price from $25 to $40 per pill

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

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

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

+ 23 Stimulants: Amphetamines n Increase alertness and motor activity n Reduce fatigue n Amphetamines n Synthetic stimulants n n n 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: n n Benzedrine, Dexedrine, Methedrine Nervousness, agitation, irritability confusion, paranoia, hostility Tolerance can develop after only 6 days use (Comer et al. , 2001)

+ 24 Stimulants: Methamphetamine n Amphetamine derivative (aka crystal meth) n Can be taken orally, intravenously, or intranasally (snorting) n In 2006, over 700, 000 people used methamphetamine (SAMHSA, 2007). n Chronic use damages brain n Reduction in hippocampus volume (see figure 10. 4; abusers represented by yellow bars)

+ 25 Stimulants: Cocaine n Alkaloid obtained from coca leaves n n Reduces pain Produces euphoria Heightens sexual desire Increases self-confidence and indefatigability n Blocks reuptake of dopamine in mesolimbic areas of brain n Overdose n n Chills, nausea, insomnia, paranoia, hallucinations; possibly heart attack & death Not all users develop tolerance n Some become more sensitive n n 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 n Crack n Form of cocaine that quickly become popular in the 80 s n Rock crystal that is heated, melted, & smoked n Cheaper than cocaine

+ 27 Hallucinogens, Ecstasy, and PCP n Hallucinogen effects include: n Colorful visual hallucinations n Synestesias n n n n Overflow from one sensory modality to another Alterations in time perception Lability of mood Anxiety & paranoia Mescaline Ecstasy n n LSD n d-lysergic acid diethylamide Psilocybin n Extracted from mushroom psylocube mexicana Increase feelings of intimacy and enhances mood Chemically similar to mescaline and amphetamines PCP (phencyclidine) n n Active ingredient of peyote n n 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 n Li et al. (2001) Two paths to alcohol abuse 1. 2. 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. n n Boys more likely to be in the first group, girls in the second group Developmental studies do not account for all cases n Not an inevitable progression through stages

+ Etiology of Substance-Related Disorders: Genetic Factors n Relatives and children of problem drinkers have higher-than-expected rates of alcohol abuse or dependence n Greater concordance in MZ than DZ twins n n In men n Alcohol, caffeine, smoking, marijuana, & drug abuse in general n n n Role of genetics less clear Fewer available studies Findings are mixed In women n Genetic and shared environmental risk factors for illicit drug abuse and dependence appear to be nonspecific n Ability to tolerate large quantities of alcohol may be an inherited diathesis n n Asians have low rates of alcohol abuse CYP 2 A 6 n n Gene associated with metabolism of nicotine Smokers with defect in this gene less likely to become dependent (Rao et al. , 2000) 30

+ 31 Etiology of Substance-Related Disorders: Neurobiological Factors n Nearly all drugs, including alcohol, stimulate the dopamine system in the brain n Some evidence that people dependent on drugs or alcohol have a deficiency in the dopamine receptor DRD 2 n People take drugs to avoid the bad feelings associated withdrawal n Explains frequency of relapse n Incentive-sensitization theory (Robinson & Berridge, 19983, 2003) n Distinguish n n n 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 n Mood n alteration Tension reduction may be due to “alcohol myopia” (Steele & Joseph, 1990) n n 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 n However, alcohol and nicotine may increase tension when no distractions are present. n n n Expectancies n n 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

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

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

+ 35 Etiology of Substance-Related Disorders: Sociocultural factors n Family factors n Parental alcohol use (Hawkins et al. , 1997) n Psychiatric, marital, or legal problems in the family linked to drug abuse n Lack of emotional support from parents increases use of cigarettes, marijuana, and alcohol (Cadoret et la. , 1995 a) n 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 n Social network n Social influence or social selection? n Bullers et al. (2001) found evidence for both n Having peers who drink influences drinking behavior (social influence) but individuals also choose friends with drinking patterns similar to their own (social selection) n Advertising n Countries and Media that ban ads have 16% less consumption than those that don’t (Saffer, 1991)

+ Treatment of Substance Related Disorders: 37 Alcohol Abuse and Dependence n Inpatient n hospital treatment Detoxification n n Withdrawal from alcohol under medical supervision The therapeutic results of hospital treatment are not superior to those of outpatient treatment n Alcoholics n n 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: Abuse and Dependence n Couples and Family Therapy n Emphasizes support from problem drinker’s partner n Reduced problem drinking maintained 1 year after therapy ended n Also reduced couples’ overall level of distress 38 Alcohol

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

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

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

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

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

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