1. PATHOPHYSIOLOGY Mental Illness and Cognitive Disorders Project Mrs. Bowman Student Name: Nemmer R. Miari April 7 th, 2015

2. Etiology  Although addiction usually (but not always) begins with a conscious decision to use a drug, changes that occur in the brain at some point can turn drug use and then abuse into a chronic, relapsing illness.  Some genetically predisposed individuals, however, become "addicted" almost immediately, with very little progression from use to abuse to dependency. 2

3. Common Signs and Symptoms of Drug Abuse  You’re neglecting your responsibilities at school, work, or home (e.g. flunking classes, skipping work, neglecting your children) because of your drug use.  You’re using drugs under dangerous conditions or taking risks while high, such as driving while on drugs, using dirty needles, or having unprotected sex.  Your drug use is getting you into legal trouble, such as arrests for disorderly conduct, driving under the influence, or stealing to support a drug habit.  Your drug use is causing problems in your relationships, such as fights with your partner or family members, an unhappy boss, or the loss of old friends. 3

4. Common Signs and Symptoms of Drug Addiction  You’ve built up a drug tolerance. You need to use more of the drug to experience the same effects you used to attain with smaller amounts.  You take drugs to avoid or relieve withdrawal symptoms. If you go too long without drugs, you experience symptoms such as nausea, restlessness, insomnia, depression, sweating, shaking, and anxiety.  You’ve lost control over your drug use. You often do drugs or use more than you planned, even though you told yourself you wouldn’t. You may want to stop using, but you feel powerless.  Your life revolves around drug use. You spend a lot of time using and thinking about drugs, figuring out how to get them, and recovering from the drug’s effects.  You’ve abandoned activities you used to enjoy, such as hobbies, sports, and socializing.  You continue to use drugs, despite knowing it’s hurting you. It’s causing major problems in your life—blackouts, infections, mood swings, depression, paranoia— but you use them anyway. 4

5. Diagnosis Methods  Some speculate that two events must occur for the addictive process to be initiated. First, there is an activation of the brain's "pleasure pathway." This occurs in the medial forebrain bundle, which runs from the brain stem and midbrain through the hypothalamus to a variety of sites in the forebrain that are concerned with emotion, motivation, reward, and decision-making.  Dopamine is the transmitter that ascends to the subcortical and cortical structures of the limbic system (in the forebrain). Dopamine's role seems to be to provide steady (tonic) regulation of the activity of the nerve cells in the limbic system.  When levels of dopamine rise significantly beyond physiologic levels (as with cocaine or amphetamine exposure), the entire medial forebrain bundle system linking dopamine-containing cell bodies with many regions of the forebrain may begin to function aberrantly. 5

6. Diagnosis Methods – Cont.  Second, for the addictive response to be initiated, the neural response to the drug exposure must have a rapid onset and must also rebound below the initial baseline of neural activity before returning to it. For example, in the case of inhaled cocaine, the drug blocks the transport of dopamine back into the nerve terminal, thereby elevating dopamine levels greatly. Dopamine levels rise rapidly to a peak that is typically several-fold greater than that achievable through physiologic stimulation (emotion, exercise) alone.  Next, dopamine levels fall rapidly and drop below the normal baseline before returning to stable values. When exposure to cocaine is repeated, the brain adapts to these drug-induced effects.  Two adaptations are of particular relevance to addiction: sensitization, an increased nerve cell response to repeated drug exposure; and learning, a reflection of enduring changes in the emotional brain as a direct result of aspects of the drug exposure that resemble other types of conditioned behavior. 6

7. Abuse vs. Dependency  There are important differences between abuse of and dependency on a drug.  Drug abuse refers to the intentional misuse or overuse of drugs. Drug abusers maintain control over their behavior. They do not have a medical disease; they have a self-imposed problem.  Drug dependency involves "impaired control" over use of the drug (this applies to all substances except certain mood-altering drugs that do not have a major effect on the medial forebrain bundle), which refers to an obsessive preoccupation with the use of the drug. 7

8. Expected Lifespan  The majority of long-term, hard-core drug addicts are dying in their 40s and 50s.  The life expectancy of a drug addict is 15 to 20 years after they start being a drug addict. 8

9. Effective Treatment Approaches  Medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic process that often begins with detoxification, followed by treatment and relapse prevention.  Easing withdrawal symptoms can be important in the initiation of treatment; preventing relapse is necessary for maintaining its effects. And sometimes, as with other chronic conditions, episodes of relapse may require a return to prior treatment components.  A continuum of care that includes a customized treatment regimen—addressing all aspects of an individual's life, including medical and mental health services—and follow–up options (e.g., community–or family-based recovery support systems) can be crucial to a person's success in achieving and maintaining a drug–free lifestyle. 9

10. DRUGS BRAIN MECHANISMS ADDICTION ENVIRONMENT HISTORY - previous history - expectation - learning - social interactions - stress - conditioned stimuli - genetics - circadian rhythms - disease states - gender BIOLOGY 10

11. And One of the Most Powerful Triggers for Relapse In Recovering Addicts And One of the Most Powerful Triggers for Relapse In Recovering Addicts Research Tells Us That STRESS Can Be A Major Factor In the Initiation of Drug Use… Research Tells Us That STRESS Can Be A Major Factor In the Initiation of Drug Use… 11 Stress and Drug Addiction

12. Research Has Also Shown That There Is Overlap Between Neuro-circuits That Respond To Drugs and Those That Respond To Stress Research Has Also Shown That There Is Overlap Between Neuro-circuits That Respond To Drugs and Those That Respond To Stress Piazza PV and Le Moal, M, Trends in Pharmacological Science, 19, February 1998; Kreek, MJ and Koob, G, Drug Alcohol Depend, 51, 1998. 12 Stress and Drug Addiction – Cont.

13. The Stress Hormone Cycle Hypothalamus Pituitary Gland Pituitary Gland Adrenal Glands Adrenal Glands Kidneys CRF ACTH CORTISOL Stress Responses 13

14. DRUG USE (Self-Medication) STRESSSTRESS CRFCRF AnxietyAnxiety CRFCRF AnxietyAnxiety What Role Does Stress Play In Initiating Drug Use? What Role Does Stress Play In Initiating Drug Use? 14

15. Prolonged DRUG USE AbstinenceAbstinence RELAPSERELAPSECRFCRF AnxietyAnxiety What Happens When A Person Stops Taking A Drug? What Happens When A Person Stops Taking A Drug? 15

16. What Do Mental and Addictive Disorders Have in Common? What Do Mental and Addictive Disorders Have in Common? Both are Behavioral Dysfunctions With Similar Neurobiological Basis Because of this overlap, drugs of abuse can cause symptoms that mimic most forms of mental illness Both are Behavioral Dysfunctions With Similar Neurobiological Basis Because of this overlap, drugs of abuse can cause symptoms that mimic most forms of mental illness 16

17. Addictive Disorder Mental Disorder Addictive Disorders Often Co-Exist With Mental Disorders 17

18. Examples of Dual Disorders  MENTAL DISORDERS  Schizophrenia  Bi-polar  Schizoaffective  Major Depression  Borderline Personality  Post Traumatic Stress  Social Phobia  Others  ADDICTION DISORDERS  Alcohol Abuse/Dependency  Cocaine/ Amphetamine  Opiates  Marijuana  Poly-substance combinations  Prescription drugs 18

19. Drug Disorder Cocaine and Methamphetamine Schizophrenia, paranoia, anhedonia, compulsive behavior Schizophrenia, paranoia, anhedonia, compulsive behavior Stimulants Anxiety, panic attacks, mania and sleep disorders Anxiety, panic attacks, mania and sleep disorders LSD, Ecstasy & psychedelics Delusions and hallucinations Alcohol, sedatives, sleep-aids and narcotics Alcohol, sedatives, sleep-aids and narcotics Depression and mood disturbances Depression and mood disturbances PCP & Ketamine Antisocial behavior 19

20. Nearly half of individuals with a past year substance use disorder also had a mental disorder Nearly half of individuals with a past year substance use disorder also had a mental disorder Mental disorders found to be most prevalent included affective disorders, anxiety disorders, personality disorders, and psychotic disorders Mental disorders found to be most prevalent included affective disorders, anxiety disorders, personality disorders, and psychotic disorders Nearly half of individuals with a past year substance use disorder also had a mental disorder Nearly half of individuals with a past year substance use disorder also had a mental disorder Mental disorders found to be most prevalent included affective disorders, anxiety disorders, personality disorders, and psychotic disorders Mental disorders found to be most prevalent included affective disorders, anxiety disorders, personality disorders, and psychotic disorders 20 Long-Term Effects

21. Lifetime Prevalence of Drug Disorders Among Persons With Various Mental Disorders (vs. any Drug Disorder Alone) Lifetime Prevalence of Drug Disorders Among Persons With Various Mental Disorders (vs. any Drug Disorder Alone) Source: Regier,D.A. et al., JAMA 264(19), pp. 2511-2518, November 21, 1990. 0 5 10 15 20 25 30 35 40 45 Schizo- phrenia Schizo- phrenia APD Anxiety Panic Disorder Panic Disorder OCD Bipolar Disorder Bipolar Disorder Depression Any Drug Disorder (alone) Any Drug Disorder (alone) 21

22. Some drugs of abuse have a mechanism of action similar to that of drugs used as psychotherapeutic agents. Significance: rationale for self-administration Chronic use of some of these drugs may alter the way the brain functions, making persons particularly susceptible to mental illness Some drugs of abuse have a mechanism of action similar to that of drugs used as psychotherapeutic agents. Significance: rationale for self-administration Chronic use of some of these drugs may alter the way the brain functions, making persons particularly susceptible to mental illness 22 Drug Abuse

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24. Works Cited 1. http://www.helpguide.org/articles/addiction/drug-abuse-and- addiction.htm http://www.helpguide.org/articles/addiction/drug-abuse-and- addiction.htm 2. http://www.mayoclinic.org/diseases-conditions/drug- addiction/basics/definition/con-20020970 http://www.mayoclinic.org/diseases-conditions/drug- addiction/basics/definition/con-20020970 3. http://www.webmd.com/mental-health/addiction/drug-abuse- addiction http://www.webmd.com/mental-health/addiction/drug-abuse- addiction 4. https://ncadd.org/learn-about-drugs/signs-and-symptoms https://ncadd.org/learn-about-drugs/signs-and-symptoms 5. http://www.medicinenet.com/drug_abuse/page2.htm http://www.medicinenet.com/drug_abuse/page2.htm 6. http://www.thefix.com/content/10-hardest-addictive-drugs- to-kick7055 http://www.thefix.com/content/10-hardest-addictive-drugs- to-kick7055 7. http://en.wikipedia.org/wiki/Substance_dependence http://en.wikipedia.org/wiki/Substance_dependence 8. http://www.drugabuse.gov/publications/drugfacts/treatment- approaches-drug-addiction http://www.drugabuse.gov/publications/drugfacts/treatment- approaches-drug-addiction 24