1. Lecture Three
The Medical Model

2. 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

3. 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

4. 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

5. 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

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

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

8. Is it not a choice?
What do folks think?

9. Is it simple a choice?

10. Is it simple a choice?
Is it simple a choice?

11. 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!

12. 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

13. 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

14. 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

15. Medical model of addiction
or Disease Model

16. 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.

17. 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

18. 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

19. 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”

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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