Lecture Three The Medical Model

DSM (2013) – 5 Alcohol Use Disorder Mild presence of 2 to 3 symptoms Moderate presence of 4 to 5 symptoms Severe presence of 6 or more

The 11 Symptoms 1. Alcohol is often taken in larger amounts or over a longer period than was intended 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol 5. Recurrent alcohol use resulting in a failure to fulfill major obligations at work, school, or home

The 11 Symptoms (cont.) 6. Continued use despite having recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use 8. Recurrent alcohol use in situations in which it is physically hazardous 9. Alcohol use is continued despite the knowledge of having recurrent physical/psychological problems likely to be caused by alcohol

The 11 Symptoms (cont.) 10. Tolerance a) need for increased amounts to achieve desired effect, or b) a markedly diminished effect with continued use of the same amount of alcohol 11. Withdrawal, as manifested by either of the following a) the characteristic withdrawal syndrome for alcohol, b) alcohol (or closely related substance) is taken to relieve or avoid withdrawal symptoms

Exploring the Medical Model…. AND IT’S ROOTS LET’S FIRST START WITH THE WHY?

Why do people abuse chemicals? But why then are we not all addicts? The simplest answer is because it feels good!

Is it not a choice? What do folks think?

Is it simple a choice?

Is it simple a choice? Is it simple a choice?

Physical reward potential Increased sense of pleasure Decreased discomfort Thus I use again and again Pleasure center is not one a single center Pleasure center across brain systems Motivated to seek further stimulation My expectation of use - psychological depedence ? How immediate is the effect? Not sufficient to cause addiction!

Social Learning Component We learn how to use drugs and substances In order to maximize their potential both physically and psychologically. Individual Expectation of Drug/Alcohol / Substance Taught learn that the substance is acceptable Recognize the effects chemical and interpret them as pleasurable

Cultural influences on chemical use patterns People’s decision to use or not can be a result of the community, subculture, family, and social group, to which you belong. Peele [1985] holds that “cultures where use of a substance is comfortable, familiar, and socially regulated both as to style of use and appropriate time and place for such use, addiction is less likely and maybe practically unknown”. And yet with new emerging addictions this may not hold as true as it did 20 years ago! What is Peele Smoking? We also can’t forget social groups within a culture Italian sub-culture in the United States Sub-groups of users – we use this drug and stick together – but we won’t use that drug >>> closer to their social norm group

Individual Life Goals Present Past Future It’s Important to remember that chemical abuse patterns are not fixed Moreover, no one sets out to become addicted

Medical model of addiction or Disease Model

Basic Tenet: Medical Model / Disease Model A great deal of the individuals behavior is based on predisposition However, there is no universally accepted disease model that explains addiction Instead there exists loosely related theories that addiction is (unproven) a psycho-biomedical process that can be called a disease state.

Otto Jellinek (1952) Influenced physicians Shifted from moral disorder to medical disorder Became recognized as formal disease in 1956 (by the AMA) Proposed alcoholism to be a progressive / predictable disorder

Jellinek’s Four Stage Model Prealcoholic Phase Prodromal Phase First Blackouts; preoccupation with use, development of guilt Alcohol used for relief from social tension PROGRESSIVEE COURSE LEADING TO DEATH Crucial Phase Chronic Phase Loss of tolerance; obsessive drinking, alcoholic tremors, drinking with social inferiors Loss of control; Physically dependent Relief drinking During the crucial phase the individual would have periods of abstinence – but would return to drinking shortly

Jellinek’s Additions Later classified different types of alcoholics One hallmark of the alcoholic – they can’t predict how much they will drink after starting His legacy – something worth studying (brain/biology) Removes prejudices “the immoral alcoholic” Wasn’t about will power was a “disease”

Genetic Inheritance Theories Less sensitive to alcohol effects – (less neuronal firing) Like / dislike certain substance(s) Decision making (frontal cortex) Make it harder to quit Affect withdrawal syndrome Different studies suggest that genes account for 20% to 58% of addiction risk No signal gene causes addiction Vulnerability not Destiny

Cloninger’s Type 1 and Type 2 Alcoholics 3,000 adoptees Reared by non-alcoholic parents Great deal of adoptees became alcoholic Cloninger observed two distinct groups

Type 1 (larger subgroup) ¾ children had biological parents who were alcoholic These children drank in moderation in early adulthood Later life developed dependence Functioned in society as responsible adults If raised in higher socio economic family less likely to become alcoholic

Type 2 Later studies confirmed findings Males More violent than Type 1 Father’s were violent alcoholics 20% chance of becoming alcoholic regardless of SES Later studies confirmed findings 10% of sample became alcoholics Low Levels of MAO

Neuro-Biological Processes, Dopamine, and Drug Addiction Addicts are biologically different from non-addicts An addict’s brain acts differently before and after using Addicts metabolize and bio-transform substances differently

Ego States and the Characterlogical Model of Addiction Personality and its relationship with self and world (internal and external) How we then deal with world Addiction then helps to self-regulate via pharmacologic effects, attendant rituals, practices, and drug culture