Substance-Related Disorders

Substance-Related Disorders Substance dependence Substance abuse Substance intoxication Substance withdrawal alcohol amphetamines caffeine cannabis cocaine hallucinogens inhalants nicotine opioids phencyclidine sedative/hypnotic/anxiolytic

Criteria for Substance Dependence A maladaptive pattern of substance abuse, leading to impairment or distress as manifested by 3 or more symptoms within a 12-mo. period tolerance a need for markedly increased amount of substance markedly diminished effect with same amount of substance withdrawal characteristic withdrawal syndrome for substance taking same substance to relieve withdrawal symptoms larger amounts over longer period than intended persistent desire or unsuccessful efforts to cut down time spent in acquiring, using, & recovering important activities given up/reduced continued use despite persistent physical or psychological problem caused by substance

Substance Dependence Specifyers: with physiological dependence (evidence of tolerance or withdrawal) without physiological dependence (no evidence of tolerance or withdrawal)

Cocaine and Physiological Brain Changes use dopamine agonists that flood synapses with DA and overshadow normal rewarding activities attempt to restore homeostasis downregulating DA receptors on post-synaptic neurons upregulating MAO lower levels of DA in synapses during “non-use” periods craving for more of the dopamine-agonist substance

Criteria for Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following: recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home recurrent substance use in which it is physically hazardous recurrent substance-related legal problems continued substance use despite having persistent interpersonal problems caused by substance Symptoms have never met criteria for Substance dependence for this drug

Criteria for Substance Intoxication The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance. B. Clinically significant maladaptive behavioral or psychological changes due to effect of substance on central nervous system belligerence mood lability cognitive impairment impaired judgment impaired social/occupational functioning C. Symptoms are not due to a medical condition or mental disorder

Alcohol-Related Disorders

Criteria for Alcohol Intoxication A. Recurrent ingestion of alcohol B. Significant maladaptive behavioral or psychological changes inappropriate sexual behavior inappropriate aggression mood lability impaired judgment C. One or more of the following signs shortly after ingestion: slurred speech incoordination unsteady gait nystagmus (involuntary eye movements) impairment in attention or memory stupor or coma D. The symptoms are not better accounted for by a medical condition or by another mental disorder.

Criteria for Alcohol Withdrawal A. Cessation of alcohol use that has been heavy and prolonged. B. Two or more of the following developing after cessation: autonomic hyperactivity (e.g., sweating, pulse over 100) increased hand tremor insomnia nausea or vomiting transient hallucinations or illusions psychomotor agitation anxiety grand mal seizures C. Symptoms cause significant distress or impairment in social/ occupational functioning D. The symptoms are not better accounted for by a medical condition or by another mental disorder.

Bad Stuff Associated with Alcohol Abuse Short-term: 25,000 highway deaths per year industrial accidents, public transportation accidents over one-half of all murders involve alcohol child and spouse abuse one-half of all suicides involve alcohol fetal alcohol syndrome Long-term: increased risk of heart disease increased risk of throat and stomach cancer cirrhosis of the liver Korsakov Syndrome (amnestic disorder) depression marital breakup loss of job and school failure

Why Do People Drink? (Cooper et al., 1995) To enhance positive feelings celebrations, social gatherings increase arousal, energy, joy desire for psychomotor activation associated with extraversion, sensation-seeking B. To cope with negative feelings reduce anxiety, depression avoidance or denial negative life event forget problems avoidance of responsibility associated with neuroticism, low self-esteem

Why Do People Drink? Dual-Pronged Method of Action interacts with mesolimbic dopamine and opioid systems initial buzz (and psychomotor activation) feelings of mild euphoria, self-confidence, sociability interacts with glutamate and GABA systems decreases glutamate increases GABA decreases anxiety and self-consciousness decreases negative mood and irritability suppresses CNS activation Note that there is a dose-dependent response to alcohol

Is There a Genetic Basis to Alcoholism? twin studies and adopted away studies indicate a genetic component adopted away SOMAs 4 times as likely to be alcoholic as adopted nonSOMAs twin studies show inheritance in males polygenetic

Cloninger’s Type I and Type II Alcoholics later onset more likely to be triggered by specific event more environmental influence equal number of males and females Type II early onset physical problems much larger heritability associated with antisocial acts more likely to be aggressive much more common in males

Factors Affecting Alcoholism

Social/Cultural Factors Affecting Alcoholism society’s attitude toward drinking peer pressure (group ID) media portrayal low SES high availability high EE in families

Psychological Factors Affecting Alcoholism expectancies sensation-seeking anxiety-proneness lack of other coping mechanisms

Biological Factors Affecting Alcoholism genetic predisposition low frontal arousal Aldehyde dehydrogenase (ALDH) deficit HR reactivity to alcohol MAO abnormalities

Is Alcohol a Disease? Disease model asserts that alcoholism is caused by a physiological defect similar to diabetes. Alternate model characterizes alcoholism as a character flaw Advantages of Disease Model brought problem to public awareness got funding to study alcoholism removes stigma got treatment developed and funded Disadvantages of Disease Model reduces addict’s accountability removes incentive to abstain places addict in victim role inconsistent with data that say “controlled” use may be achieved self-fulfilling prophesy

Treatment of Alcoholism Biological detoxification (benzodiazapines) disulfiram (Antabuse) Naltrexone acamprosate (Campral) Psychological Alcoholics Anonymous Cognitive Behavioral treatments Controlled Drinking Social token economy

The COMBINE Study Best outcome: Naltrexone plus medical management or JAMA (2006) Best outcome: Naltrexone plus medical management or 10-20 session CBT plus medical management

Questions of the Week: 1. Do you feel that alcoholism is a disease or a failure of will power and self-control? Why? 2. Can alcoholics successfully achieve controlled drinking, or is total abstinence the only option? Justify your answer with information from the readings and lecture. Recommended Movie of the Week: Days of Wine and Roses starring Jack Lemon Lee Remick