Substance-Related and Impulse Control Disorders

Levels of Involvement – Substance Disorders Terminology Rate of use illegal substances: 8% Specific drugs have specific effects, but terminology applies to all

Psychoactive substances: alter mood or behavior Substance use: moderate ingestion of psychoactive substances, does not interfere with functioning

Intoxication Intoxication: physiological reactions resulting from ingestion of psychoactive substance Impaired judgment Changes in motor ability Mood changes

Substance Abuse Substance abuse: pattern of substance use that leads to significant distress or impairment in roles, and in hazardous situations

Substance Dependence Substance dependence: characterized by need for increased amounts to achieve desired effect (tolerance) Negative physical effects when withdrawn (withdrawal)

Substance Dependence Dependence is also marked by: Unsuccessful attempts at control Substantial effort expended to seek Substantial effort to recover

Psychiatric Definition – 3 of 9 required for addiction TAKES more than intended WANTS to cut back, but has failed SPENDS lots of time trying to get or do OFTEN intoxicated or in withdrawal CURTAILS other activities USES substance despite problems it causes NEEDS more and more of substance to achieve effect SUFFERS withdrawal TAKES substance to avoid withdrawal

Relative Addictiveness Based on Expert Ratings

Diagnostic Specifics Diagnoses are given by Substance Dependence, abuse, intoxication, withdrawal Other disorders can complicate picture

Individual Substances 1. Depressants: sedation, relaxation. Include alcohol, sedative drugs 2. Stimulants: increase activity, alertness, mood. Amphetamines, cocaine, nicotine, caffeine 3. Opiods: reduce pain and increase euphoria. Heroin, opium, morphine 4. Hallucinogens: alter sensory perception. Marijuana, LSD

Depressants Alcohol Sedatives

Alcohol Abuse 23% Americans binge drink (5+) 15 million Americans are alcohol dependent Very culturally dependent Peru: 25% Shanghai: 0.45% Dependency is chronic Earlier age (11-14) = increased risk disorder

Sedative Use Disorders Calming, sleep-inducing, anxiety reducing Barbituates ↓ Common use for suicide (suffocation) Benzodiazepines ↑ Less than 1% of treatment seekers

Description & Effects of Alcohol Initial depression of inhibitory centers Spreads to motor coordination, reaction time, judgments, etc Withdrawal can be severe Hand tremors, nausea & vomiting, anxiety, hallucinations, insomnia, agitation, delirium Long-term abuse can lead to dementia

Stimulants Amphetamines Cocaine Nicotine Caffeine

Amphetamine Use Disorders Elation → Crashing Man-made asthma, nasal decongestant Weight loss, narcolepsy, ADHD

Diagnostic criteria Behavioral symptoms Changes in affect Sociability, interpersonal sensitivity Anxiety, anger Impaired judgment Quick tolerance

Cocaine Use Disorders Short-lived high, paranoia is common (2/3) Dependence is different Inability to resist increases Few early negative effects Lack of sleep, paranoia Withdrawal leads to severe apathy

Opiods Natural, synthetic, endogenous to body Euphoria, drowsiness, slowed breathing Analgesics (e.g., morphine) Very unpleasant withdrawal 6-12 hours Yawning, nausea, vomiting, chills, muscle aches, diarrhea, insomnia (1-3 days) Poor prognosis

Hallucinogens (LSD) Synthetically produced Quick tolerance Lack of effect over days Little reported withdrawal Mechanism unknown Long-term effects unknown

Other Substances of Abuse Inhalants Most common poor adolescent males Steroids “Designer drugs”

Causes of Substance Abuse Disorders 1. Biological Factors Genetic Neurobiological 2. Psychological Factors Reinforcement Cognitive Factors Social Factors Culture 3. Integrative Model

Biological Influences - Genes Drug abuse (particularly alcohol) have genetic influence Easiest to study alcohol Common genetics? Use = environment, abuse = genetic?

Biological Influences - Neurobiology Positive reinforcement of natural pleasure states neurologically Dopaminergic system + opiods How does negative reinforcement work?

Psychological Influences – Positive and Negative Reinforcement Positive reinforcement can be physical Also social Negative reinforcement = relief (Such as anxiety, pain, etc.) Used to “self medicate”

Cognitive Factors Expectancy effects Predict future drinking use by teens Drinking will improve social behavior, motor, and cognitive abilities Expectancies might result from us Cravings Influenced by cognitions – availability, environment, moods

Social Factors Exposure to substances influences disorder development Media exposure, peer exposure Less monitoring by parents with disorder

Cultural Influences Cultural expectations for drug use Economic influences

An Integrative Model Textbook p. 415 All influences work together to increase likelihood of substance disorder Also influences the maintenance of that disorder Equifinality: a particular disorder can arise from multiple and different paths

Treatment of Substance- Related Disorders Personal motivation is essential Difficult and slow Individualized Treatments across type of drug very similar 1. Biological Treatments 2. Psychosocial Treatments

Biological Treatments – Agonist Substitution Patient is provided with safe drug that has similar chemical makeup E.g. methadone (opiod) for heroin No high, but same analgesic and sedation Results are mixed Cross-tolerance Abuse of other drugs Lifelong dependency

Biological Treatments – Antagonist Treatment Effects of drug are blocked, so no longer produce pleasant results Naltrexone – produces immediate withdrawal symptoms from opiods Might also help with alcoholism, with therapy

Biological Treatments – Aversive Treatment Make ingesting psychoactive drug unpleasant Associate drug use with side effects Antabuse Nausea, vomiting, elevated heart rate, respiration Noncompliance is large problem

Psychological Treatments 1. Inpatient treatment 2. Alcoholics Anonymous (and variants) 3. Controlled Use 4. Component Treatment 5. Relapse Preventions

Inpatient Treatment Help addicts through initial withdrawal Expensive May be no difference between inpatient and outpatient care Environment is different

Alcoholics Anonymous Developed 1935 Alcoholism as a disease that requires lifelong management High levels of social support 97,000 groups in 100 countries 3% of Americans report attending at least 1 meeting in their lifetime Relies on prayer and belief in higher power Research on AA is very difficult

Controlled Use Alternative to total abstinence Some may become social users Extremely controversial both controlled use and abstinence is successful for only 20-30% of patients

Component Treatment Aversion therapy – use paired with punishment Covert sensitization Contingency management – rewards Community reinforcement – address life Close other participates Identify antecedents and consequences Assistance with social services New recreational activities

Relapse Prevention Learned aspects of dependence Relapse = failure of cognitive and behavioral coping skills Target ambivalence Positive aspects Negative consequences Identify high risk situations and plan

Impulse-Control Disorders 1. Intermittent Explosive Disorders 2. Kleptomania 3. Pyromania 4. Pathological Gambling 5. Trichotillomania 6. Problematic Internet Use

Intermittent Explosive Disorder Aggressive impulses Result in serious assault or destruction of property Rarely diagnosed Symptoms often accounted for by another disorder

Kleptomania Urges to steal things Not needed for personal use or monetary value Rare? (Difficult to study) Urge brings sense of tension, which is relieved by stealing

Pyromania Urge to set fires Pattern similar to kleptomania (tension & relief) Less than 4% of arsonists Very little research

Pathological Gambling Increasing number of patients 3-5% of adult Americans Increasing among adolescents Similar criteria to substance abuse Increasing amounts for “high” Withdrawal Interference with functioning

Pathological Gambling fMRIs show decreased activation in regions of brain that regulate impulses, while gambling Abnormalities in dopamine and serotonin Gambler’s Anonymous 70-90% drop out Need high motivation

Trichotillomania Urge to pull out one’s hair 1-5% of college students Greater incidence in females Antidepressants & Cognitive therapy seem to have effect Research is very scarce

Internet Addiction Excessive gaming, sexual preoccupation, and/or /text use 1. Excessive Use Loss of time, neglect of basic drives 2. Withdrawal Anger, tension, depression when inaccessible 3. Tolerance Better equipment, new software, longer times 4. Negative Repercussions Lying, arguments, academic achievements, social isolation

Internet Addiction Difficult to research In US, Internet and computers are accessed from home 86% estimated to have comorbidity Shame, denial, motivation, lack of awareness Estimated % prevalence in US