Substance-Related and Impulse-Control Disorders Chapter 14 Substance-Related and Impulse-Control Disorders

DSM-5 Proposal Combine the substance-related and impulse-control disorders into one new category, addiction and related disorders.

Substance Abuse A substance is any natural or synthesized product that has psychoactive effects—it changes perceptions, thoughts, emotions, and behaviors.

In the United States, ethnic and age groups have different rates of drug use

The rate of illegal drug use by young adults has fluctuated over time

Substance-Related Conditions Recognized by the DSM-IV-TR Substance intoxication: Experience of significant maladaptive behavioral and psychological symptoms due to the effect of a substance on the central nervous system. Substance withdrawal: Experience of clinical significant distress in social, occupational, or other areas of functioning due to the cessation or reduction of substance use.

Substance-Related Conditions Recognized by the DSM-IV-TR, continued Substance abuse: Diagnosis given when recurrent substance use leads to significant harmful consequences. Substance dependence: Diagnosis given when substance use leads to physiological dependence or significant impairment or distress.

Five categories of abused substances (1) central nervous system depressants, including alcohol, barbiturates, benzodiazepines, and inhalants (2) central nervous system stimulants, including cocaine, amphetamines, nicotine, and caffeine (3) opioids, including heroin and morphine (4) hallucinogens and phencyclidine (PCP) (5) cannabis

DSM-IV-TR Criteria for Substance Abuse One or more of the following occurs during a 12-month period, leading to significant impairment or distress: Failure to fulfill important obligations at work, home, or school as a result of substance abuse. Repeated use of the substance in situations in which it is physically hazardous to do so. Repeated legal problems as a result of substance use. Confirmed use of the substance despite repeated social or legal problems as a result of use.

DSM-IV-TR Criteria for Substance Dependence Maladaptive pattern of substance use, leading to three or more of the following: Tolerance, as defined by either the need for markedly increased amounts of the substance to achieve intoxication or desired effect; markedly diminished effect with continued use of the same amount. Withdrawal, as manifested by either: the characteristic withdrawal syndrome for the substance; the same or closely related substance is taken to relieve or avoid withdrawal symptoms. The substance is often taken in larger amounts or over a longer period than was intended.

DSM-IV-TR Criteria for Substance Dependence, continued Persistent desire or unsuccessful efforts to cut back or control use. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. Important social, occupational, or recreational activities are given up or reduced because of substance use. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by the substance.

DSM-5 Proposal Substance abuse and dependence may be combined in one diagnosis to be called substance-use disorder. Diagnostic criteria for substance-use disorder will include: continued use of substances despite negative social, occupational, and health consequences evidence of tolerance or withdrawal. “Craving the substance” will be added because it is a common symptom of abuse/dependence “Legal problems” will be removed from the criteria

Depressants Depressants slow the central nervous system. In moderate doses, they make people relaxed and somewhat sleepy, reduce concentration, and impair thinking and motor skills. Includes alcohol, benzodiazepines, barbiturates, and inhalants.

Alcohol Alcohol abuse Alcohol dependence Binge drinking Withdrawal

Long-term Effects of Alcohol Abuse Low-grade hypertension Alcohol-induced persisting amnesic disorder Wernicke’s encephalopathy Korsakoff’s pyschosis Alcohol-induced dementia

Cultural Differences in Alcohol Disorders

Ethnic Differences in Alcohol Use in the United States

Gender Differences

Benzodiazepines and Barbiturates Benzodiazepines (such as Xanax, Valium, Halcion, and Librium) and barbiturates (such as Quaalude) are legally manufactured and sold by prescription, usually for the treatment of anxiety and insomnia. Two common patterns of abuse can develop with these substances: 1. adolescents using them for recreational purposes 2. people (particularly women) using initially under physician’s care but then increasing doses as tolerance develops

Inhalants Inhalants: solvents such as gasoline, glue, paint thinners, and spray paints. Greatest users of inhalants are young boys between 10 and 15 years of age. Chronic users may have a variety of respiratory irritations and rashes. Can also cause permanent damage to the central nervous system, and can lead to organ failure and death.

Stimulants Activate the central nervous system, causing feelings of energy, happiness, and power, a decreased desire for sleep, and a diminished appetite Include cocaine and the amphetamines (including the related drugs methamphetamines) Impart a psychological lift or rush Cause dangerous increases in blood pressure and heart rate, alter the rhythm and electrical activity of the heart, and constrict the blood vessels, which can lead to heart attacks, respiratory arrest, and seizures Caffeine and nicotine Prescription stimulants, including Dexedrine and Ritalin

Stimulants: Cocaine Symptoms include: behavioral changes (e.g., euphoria or affective blunting; impaired judgment) rapid heartbeat, dilation of pupils, elevated or lowered blood pressure weight loss, nausea or vomiting muscular weakness slowed breathing, chest pain, confusion seizures, coma

Stimulants: Amphetamines Used to combat depression or fatigue or boost energy and self-confidence; also in diet drugs Cause the release of dopamine and norepinephrine and clock reuptake Symptoms of intoxication are similar to cocaine intoxication

Stimulants: Nicotine No DSM-IV-TR diagnosis for the symptoms, but nicotine operates on both the central and peripheral nervous system Results in the release of several biochemicals that may have direct reinforcing effects on the brain, including dopamine, norepinephrine, serotonin, and the endogenous opioids

Stimulants: Nicotine, continued Withdrawal Symptoms dysphoria or depressed mood insomnia irritability frustration or anger anxiety difficulty concentrating restlessness decreased heart rate increased appetite or weight gain

Stimulants: Caffeine The most heavily used stimulant drug 75% of caffeine ingested through coffee The average American drinks about two cups of coffee per day; a cup of brewed coffee has about 100 milligrams of caffeine Caffeine stimulates the central nervous system increasing levels of dopamine, norepinephrine, and serotonin

Stimulants: Caffeine, continued Symptoms: Restlessness, nervousness, excitement, insomnia, flushed face, frequent urination, stomach upset, muscle twitching, rambling flow of thought or speech, rapid heartbeat, periods of inexhaustibility, psychomotor agitation Withdrawal Symptoms: Marked fatigue or drowsiness, increased appetite or weight gain, marked anxiety or depression, nausea or vomiting

Opioids- derived from the opium poppy Morphine Heroin Codeine Methadone

Hallucinogens and PCP Hallucinogens are a mixed group of substances including LSD, MDMA (also called ecstasy), and peyote. PCP, also known as angel dust, is a manufactured as a powder to be snorted or smoked. Although not classified as a hallucinogen, it has many of the same effects.

Cannabis The leaves of the cannabis (or hemp) plant can be cut, dried, and rolled into cigarettes or inserted into food and beverages. In North America, the result is known as marijuana, weed, pot, grass, reefer, and Mary Jane Cannabis is the most commonly used illegal drug in the United States, with about 40% of the population reporting use of it at some time in their lives, and 6% in the last month About 7% of the population would qualify for a diagnosis of cannabis abuse, and 2 to 3% for a diagnosis of cannabis dependence Occasional use is widespread: 30% of college students say they have used cannabis in the last year

Theories of Substance Use, Abuse, and Dependence These substances affect several biochemicals that can have direct reinforcing effects on the brain. The brain appears to have its own “pleasure pathway” that affects our experience of reward

BRAIN MAP SHOWINGSEPTAL/HIPPOCAMPAL

Biological Theories Genetic Factors Reward Sensitivity Family history, adoption, and twin studies all suggest that genetics may play a substantial role in at least some forms of addiction. Reward Sensitivity Substantial individual differences in sensitivity to the rewarding properties of substances.

Psychological Theories Social-learning theories: Children and adolescents learn alcohol-related behaviors from the modeling of their parents and important others in their culture. Cognitive theories: focus on people’s expectations of its effects and their beliefs about the appropriateness of using it to cope with stress. Personality characteristic of behavioral under control: the tendency to be impulsive, sensation-seeking, and prone to antisocial behaviors such as violating laws.

Sociocultural Approaches Chronic stress combined with an environment that supports and even promotes the use of substances as an escape is a recipe for widespread substance abuse and dependence. Substance use, particularly alcohol use, is much more acceptable for men than for women in many societies. When women do become substance abusers, their patterns of use and reasons for use tend to differ from men’s.

Treatments for Substance-Related Disorders Biological Treatments Medications, including antianxiety drugs, antidepressants, and antagonists Methadone Maintenance Programs Behavioral and Cognitive Treatments Aversive classical conditioning Covert sensitization therapy Contingency management programs Cognitive treatments Motivational interviewing Relapse prevention Alcoholics Anonymous

Impulse-Control Disorders Include kleptomania, pyromania, pathological gambling, intermittent explosive disorder, and trichotillomania People with these disorders often feel a mounting sense of tension relieved only by engaging in their impulsive act Some researchers consider these disorders to be similar to substance-related disorders, and due to abnormalities in reward systems in the brain Others consider them to be part of the obsessive-compulsive disorder continuum DSM-5 authors have proposed moving these disorders to various categories depending on the available research for each disorder