1. Substance-Related and Impulse-Control Disorders
Chapter 10
Substance-Related and Impulse-Control Disorders

2. Perspectives on Substance-Related Disorders
The nature of substance-related disorders
Use and abuse of psychoactive substances
Wide-ranging physiological, psychological, and behavioral effects
Associated with impairment and significant costs
Technology Tip: National Clearinghouse for Alcohol and Drug Information. This web site provides a wealth of information about substance use and abuse provided by the Department of Health and Human Services.

3. Perspectives on Substance-Related Disorders
Some important terms and distinctions
Substance use vs. substance intoxication
Substance abuse vs. substance dependence
Tolerance vs. withdrawal

4. Five Main Categories of Substances
Depressants
Behavioral sedation (e.g., alcohol, sedative, anxiolytic drugs)
Stimulants
Increase alertness and elevate mood (e.g., cocaine, nicotine)

5. Five Main Categories of Substances
Opiates
Produce analgesia and euphoria (e.g., heroin, morphine, codeine)
Hallucinogens
Alter sensory perception (e.g., marijuana, LSD)
Other drugs of abuse
Include inhalants, anabolic steroids, medications

6. FIGURE 10. 1 Easy to get hooked on, hard to get off
FIGURE 10.1  Easy to get hooked on, hard to get off. (Reprinted, with permission, from Hastings, J., 1990, November/December. Easy to get hooked on, hard to get off. In Health, p. 37, © 1990 In Health.)

7. FIGURE 10.2  The path traveled by alcohol throughout the body (see text for complete description).

8. The Depressants: Alcohol Use Disorders
Psychological and physiological effects of alcohol
Central nervous system depressant
Influences several neurotransmitter systems
Specific target is GABA
Technology Tip: Alcoholics Anonymous. The official web page for Alcoholics Anonymous; information includes the "Twelve Steps to Recovery".

9. The Depressants: Alcohol Use Disorders
Effects of chronic alcohol use
Alcohol intoxication and withdrawal
Associated brain conditions – dementia and Wernicke’s disease
Fetal alcohol syndrome
DSM-IV-TR criteria for disordered alcohol use

10. FIGURE 10. 3 Alcohol use across racial groups
FIGURE 10.3  Alcohol use across racial groups. Binge drinking is defined as drinking five or more drinks on one occasion at least once per month, and heavy alcohol use is defined as binge drinking for five or more days in a month. (From Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Results from the 2005 National Survey on Drug Use and Health: National Findings, NSDUH Series H-30, DHHS Publication No. SMA Rockville, MD: Author.)

11. Alcohol: Some Facts and Statistics
In the United States
Most adults consider themselves light drinkers.
92% will use in lifetime
Alcohol use is highest among Caucasian Americans (56.5%)
Males use and abuse alcohol more than females
23% of Americans report binge drinking
Violence is associated with alcohol
Alcohol alone does not cause aggression

12. Alcohol: Some Facts and Statistics
Statistics on abuse and dependence
Three million Americans are alcohol dependent
20% with alcohol problems experience spontaneous recovery
Diversity and alcohol use

13. FIGURE 10. 4 Relapse rates for nicotine compared to alcohol and heroin
FIGURE 10.4  Relapse rates for nicotine compared to alcohol and heroin. Smokers trying to give up cigarettes backslide about as often as alcoholics and heroin addicts. (Adapted, with permission, from Kanigel, R., 1988, October/November. Nicotine becomes addictive. Science Illustrated, pp. 12–14, 19–21, © 1988 Science Illustrated.)

14. Sedative, Hypnotic, or Anxiolytic Substance use Disorders: An Overview
The nature of drugs in this class
Sedatives – calming (e.g., barbiturates)
Hypnotic – sleep inducing
Anxiolytic – anxiety reducing (e.g., benzodiazepines)

15. Sedative, Hypnotic, or Anxiolytic Substance use Disorders: An Overview
Effects are similar to large doses of alcohol
Combining such drugs with alcohol is synergistic
All exert their influence via the GABA neurotransmitter system
DSM-IV-TR criteria for this class of disorders

16. Stimulants: An Overview
Nature of stimulants
Most widely consumed drug in the United States
Such drugs increase alertness and increase energy
Examples include amphetamines, cocaine, nicotine, and caffeine
Behavioral symptoms - euphoria or affective blunting
Physiological symptoms - heart rate and blood pressure changes, perspiration or chills, nausea or vomiting, weight loss, muscular weakness, respiratory depression, chest pain, seizures, or coma. Severe intoxication or overdose can cause hallucinations, panic, agitation, and paranoid delusions. Symptoms of withdrawal are similar to depression.

17. Stimulants: Amphetamine Use Disorders
Effects of amphetamines
Produce elation, vigor, reduce fatigue
Such effects are followed by extreme fatigue and depression
Amphetamines stimulate CNS by
Enhancing release of norepinephrine and dopamine
Reuptake is subsequently blocked
Ritalin

18. Stimulants: Amphetamine Use Disorders
DSM-IV-TR criteria for amphetamine intoxication
Ecstasy and ice
Produces effects similar to speed, but without the crash
Both drugs have a high risk of dependence

19. Stimulants: Cocaine Use Disorders
Effects of cocaine
Short lived sensations of elation, vigor, reduce fatigue
Effects result from blocking the reuptake of dopamine
Highly addictive, but addiction develops slowly
1.9 million report use in US each year
Most cycle through patterns of tolerance and withdrawal
DSM-IV-TR criteria for cocaine intoxication and withdrawal
Technology Tip: Cocaine Anonymous Home Page. This group uses the Twelve Steps program to help recovering cocaine addicts. Includes phone numbers for local chapters as well as web links.

20. Stimulants: Nicotine Use Disorders
Effects of nicotine
Stimulates nicotinic acetylcholine receptors in CNS
Results in sensations of relaxation, wellness, pleasure
Highly addictive
Relapse rates equal those seen with alcohol and heroin
DSM-IV-TR criteria for nicotine withdrawal

21. Stimulants: Nicotine Use Disorders
Nicotine users dose themselves to maintain a steady state of nicotine
Smoking has complex relationship to negative affect
Appears to help improve mood in short-term
Depression occurs more in those with nicotine dependence

22. Stimulants: Caffeine Use Disorders
Effects of caffeine – the “gentle” stimulant
Used by over 90% of Americans
Found in tea, coffee, cola drinks, and cocoa products
Small doses elevate mood and reduce fatigue
Regular use can result in tolerance and dependence
Caffeine blocks the reuptake of the neurotransmitter adenosine
DSM-IV-TR criteria for caffeine intoxication

23. Opioids: An Overview The nature of opiates and opioids
Opiate – natural chemical in the opium poppy with narcotic effects
Opioids – natural and synthetic substances with narcotic effects
Often referred to as analgesics

24. Opioids: An Overview Effects of opioids
Activate body’s enkephalins and endorphins
Low doses induce euphoria, drowsiness, and slowed breathing
High doses can result in death
Withdrawal symptoms can be lasting and severe
DSM-IV-TR criteria for opioid intoxication and withdrawal
Mortality rates are high for opioid addicts
High risk for HIV infection

25. Hallucinogens: An Overview
Nature of hallucinogens
Change the way the user perceives the world
May produce
Delusions, paranoia, hallucinations, altered sensory perception
Examples include marijuana, LSD
15.2 million in US used marijuana in last month

26. Hallucinogens: Marijuana and LSD
Active chemical is tetrahydrocannabinol (THC)
Symptoms - mood swings, paranoia, hallucinations
Impairment in motivation is not uncommon
Withdrawal and dependence are uncommon

27. Hallucinogens: Marijuana and LSD
LSD and other hallucinogens
LSD is most common form of hallucinogenic drug
Tolerance is rapid and withdrawal symptoms are uncommon
Can produce psychotic delusions and hallucinations
DSM-IV-TR criteria for marijuana and hallucinogen intoxication
Psychological and physiological symptoms are similar

28. Other Drugs of Abuse: Inhalants
Nature of inhalants
Substances found in volatile solvents
Breathed directly into lungs
Examples
Spray paint, hair spray, paint thinner, gasoline, nitrous oxide

29. Other Drugs of Abuse: Inhalants
Properties and consequences
Rapidly absorbed
Effects similar to alcohol intoxication
Tolerance and prolonged symptoms of withdrawal are common

30. Other Drugs of Abuse: Anabolic Steroids
Nature of anabolic-androgenic steroids
Steroids are derived or synthesized from testosterone
Used medicinally or to increase body mass
Users may engage in cycling or stacking
Do not produce a high
Can result in long-term mood disturbances and physical problems

31. Other Drugs of Abuse: Designer Drugs
Drugs produced by pharmaceutical companies for diseases
Ecstasy
MDEA (“eve”)
BDMPEA (“nexus”)
Ketamine (“special K”)
Phencyclidine (PCP)

32. Other Drugs of Abuse: Designer Drugs
All heighten auditory and visual perception, sense of taste/touch
Becoming popular
Nightclubs, raves, or large social gatherings
All designer drugs
Produce tolerance and dependence

33. Causes of Substance-Related Disorders: Family and Genetic Influences
Results of family, twin, and adoption studies
Substance abuse has a genetic component
Much of the focus has been on alcoholism
Genetic differences in alcohol metabolism
Multiple genes are involved in substance abuse
Technology Tip: Center for Education and Drug Abuse Research (CEDAR) CEDAR serves to elucidate the factors contributing to the variation in the liability to drug abuse and determine the developmental pathways culminating in drug abuse outcome, normal outcome, and psychiatric/behavioral disorder outcome. CEDAR is a consortium between the University of Pittsburgh and St. Francis Medical Center.

34. Causes of Substance-Related Disorders: Neurobiological Influences
Results of neurobiological research
Drugs affect the pleasure or reward centers in the brain
The pleasure centers
Dopamine, midbrain, frontal cortex
GABA turns off reward-pleasure system
Inhibition of neurotransmitters for anxiety/negative affect
Technology Tip: National Institute on Drug Abuse (NIDA). This site provides a wealth of information about drug abuse, drug treatment, and current research, including informative fact sheets about most major drugs of abuse.

35. Causes of Substance-Related Disorders: Psychological Dimensions
Role of positive and negative reinforcement
Substance abuse as a means to cope with negative affect
The self-medication and the tension reduction hypotheses

36. Causes of Substance-Related Disorders: Psychological Dimensions
Opponent-process theory
Why the crash after drug use fails to keep people from using
Cognitive factors
Role of expectancy effects
Expectancies influence drug use and relapse
Cravings

37. Causes of Substance-Related Disorders: Social and Cultural Dimensions
Exposure to drugs in a prerequisite for use of drugs
Media, family, peers
Parents and the family appear critical
Societal views about drug abuse
Sign of moral weakness – failure of self-control
Sign of a disease – caused by some underlying process

38. Causes of Substance-Related Disorders: Social and Cultural Dimensions
The role of cultural factors
Influence the manifestation of substance abuse

39. An Integrative Model of Substance-Related Disorders
Exposure or access to a drug
Is necessary, but not sufficient
Drug use depends on:
Social and cultural expectations
The pleasurable consequences

40. An Integrative Model of Substance-Related Disorders
Drugs are abused
For many complex reasons
The premise of equifinality
Consider psychological, genetic, social, and learning factors

41. FIGURE 10.5  An integrative model of substance-related disorders.

42. Biological Treatment of Substance-Related Disorders
Agonist substitution
Safe drug with a similar chemical composition as the abused drug
Examples include methadone and nicotine gum or patch
Antagonistic treatment
Drugs that block or counteract the positive effects of substances
Examples include naltrexone for opiate and alcohol problems

43. Biological Treatment of Substance-Related Disorders
Aversive treatment
Drugs that make use of substances extremely unpleasant
Examples include antabuse and silver nitrate
Efficacy of biological treatment
Generally ineffective when used alone
Used to help with withdrawal symptoms

44. Psychosocial Treatment of Substance-Related Disorders
Inpatient vs. outpatient care
Little difference in effectiveness
Community support programs
Alcoholics Anonymous (AA) and related groups (e.g., NA)
Seem helpful and are strongly encouraged
Balancing treatment goals
Controlled use vs. complete abstinence
Controlled drinking
Component treatment
Technology Tip: Visit the UW Addictive Behaviors Research Center website:

45. Psychosocial Treatment of Substance-Related Disorders
Comprehensive treatment and prevention programs
Individual and group therapy
Aversion therapy and convert sensitization
Contingency management
Community reinforcement
Relapse prevention
Preventative efforts
Move from education
Laws changes

46. Summary of Substance-Related Disorders
DSM-IV-TR substance related disorders
Cover four classes
Depressants, stimulants, opiates, and hallucinogens
Diagnoses include dependence, abuse, intoxication, or withdrawal

47. Summary of Substance-Related Disorders
Most substances activate the dopaminergic pleasure pathway
Psychosocial factors interact with biological influences
Treatment of substance dependence
Largely unsuccessful
Highly motivated persons do best
Important to use comprehensive approach

48. “Inside Addiction” 04:57

49. Impulse-Control Disorders
DSM-IV-TR
Intermittent explosive disorder
Kleptomania
Pyromania
Pathological gambling
Trichotillomania

50. Impulse-Control Disorders
Each is characterized by
Increased tension/anxiety prior to the act
A sense of relief following the act
Impairment of social and occupational functioning

51. Impulse-Control Disorders: Intermittent Explosive Disorder
Rare condition
Characterized by frequent aggressive outbursts
Leads to injury and/or destruction of property
Few controlled treatment studies
Technology Tip: For more information on Intermittent Explosive Disorder, visit the Mayo Clinic site:

52. Impulse-Control Disorders: Kleptomania
Failure to resist urge to steal unnecessary items
Seems rare, but it is not well studied
Highly comorbid with mood disorders
Also co-occurs with substance-related problems
Technology Tip: For more information on kleptomania, visit the following site:

53. Impulse-Control Disorders: Pyromania, Pathological Gambling
Involves having an irresistible urge to set fires
Diagnosed in less than 4% of arsonists
Little etiological and treatment research
Pathological gambling
Affects 3-5% adult Americans
Treatment is similar to that for substance dependence
Technology Tip: For more information on pyromania, visit the following website:
Technology Tip: National Council on Problem Gambling. This web site is a great resource about issues related to problem gambling and its treatment.

54. Impulse-Control Disorders: Trichotillomania
Inability to resist the urge to pull hair
Observed in 1-5% of college students, mostly female
Clomipramine and CBT have been shown to be helpful
Technology Tip: The Trichotillomania Learning Center provides information, support, and referral resources to all who inquire about the experience and treatment of compulsive hair pulling: