Abnormal psychology eleventh edition by ann m kring gerald c davison john m neale sheri l johnson
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Chapter 10 Substance Related Disorders. Abnormal Psychology, Eleventh Edition by Ann M. Kring, Gerald C. Davison, John M. Neale, & Sheri L. Johnson. Percentage of Indonesian Population Reporting Drug Use in 2003-2006 (Based on BNN survey). Based on areas. Based on substance.

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Chapter 10 Substance Related Disorders

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Chapter 10 Substance Related Disorders

Abnormal Psychology, Eleventh EditionbyAnn M. Kring, Gerald C. Davison, John M. Neale, & Sheri L. Johnson


Percentage of Indonesian Population Reporting Drug Use in 2003-2006 (Based on BNN survey)

Based on areas

Based on substance

  • Jakarta : 23%

  • Medan : 15%

  • Bandung : 14%

  • Surabaya : 6.3 %

  • Maluku utara : 4.3 %

  • Padang : 5.5 %

  • Kendari : 5%

  • Marijuana : 74.9 %

  • Anti-Depressant : 32.5 %

  • Ecstasy : 25.7 %

  • Amphetamine : 21.5 %


Substance Dependence and Abuse

Dependence ( Adiction)

Abuse

  • Occupational or social problems, much time trying to obtain substance, continued use despite problems, etc.

  • Involves either tolerance or withdrawal

    • Tolerance

      • Greater amounts required to produce desired effect

    • Withdrawal

      • Physiological and psychological consequences when individual discontinues or reduces substance use

        • Restlessness, anxiety, cramps, death

    • Maladaptive use of substance

    • No physiological dependence

  • In 2006, 22 million met criteria for dependence or abuse.

    • Of those 15 million involved alcohol.


  • Alcohol Dependence and Abuse

    • Alcohol abuse

      • Negative social and occupational effects

      • No tolerance, withdrawal, or compulsive usage

    • Alcohol Dependence

      • More severe symptoms such as tolerance and withdrawal

      • Withdrawal results in:

        • Anxiety

        • Depression

        • Weakness

        • Restlessness

        • Insomnia

        • Muscle tremors

          • Face, fingers, eyelids, other small musculature

        • Elevated BP, pulse, temperature


    Alcohol Abuse and Dependence

    • Delirium tremens (DTs)

      • Can occur when blood alcohol levels drop suddenly

      • Results in:

        • Deliriousness

        • Tremulousness

        • Hallucinations

          • Primarily visual; may be tactile

    • 2.5% of alcohol abusers develop dependence


    Alcohol Abuse and Dependence

    • Polydrug abuse

      • Many users abuse multiple substances

        • e.g., cigarettes, cocaine, marijuana

        • 85% of alcohol are smokers

    • Synergistic

      • Some combinations of drugs produce stronger reaction

        • Alcohol and barbiturates

          • May cause death

        • Alcohol and heroin

          • Alcohol reduces amount of heroin needed to produce lethal dose


    Prevalence of Alcohol Abuse

    • Lifetime prevalence (Kessler et al., 1994)

      • 20% for men

      • 8% for women

    • Lifetime prevalence:

      • Abuse - 17%

      • Dependence – 12%

    • Binge drinking

      • 5 drinks in short period

      • 43.5% prevalence among college students

    • Heavyuse drinking

      • 5 drinks, 5 or more times in a 30 day period

        • 17.6% prevalence among college students


    Short-term Effects of Alcohol

    • Enters the bloodstream through small intestine

      • metabolized by the liver

    • Effects vary by concentration

      • Concentration varies by gender, height, weight, liver efficiency

        Affects brain areas associated with error monitoring and decision making.

    • Biphasic effect

      • Initially stimulates

      • Later depresses


    Short-term Effects of Alcohol

    • Effect of ingesting large amounts

      • Impaired speech and vision

      • Interference in complex thought processes

      • Poor coordination

      • Loss of balance

      • Depression and withdrawal

    • Interacts with several neural systems

      • Stimulates GABA receptors

      • Increases dopamine and serotonin

      • Inhibits glutamate receptors


    Long-term Effects of Alcohol

    • Malnutrition

      • Alcohol interferes with digestion and absorption of vitamins from food

    • Deficiency of B-complex vitamins

      • Amnestic syndrome

        • Severe loss of memory for both long and short term information

    • Cirrhosis of the liver

      • Liver cells engorged with fat and protein impeding functioning

      • Cells die triggering scar tissue which obstructs blood flow

    • Damage to endocrine glands and pancreas

    • Heart failure

    • Erectile dysfunction

    • Hypertension

    • Stroke

    • Capillary hemorrhages

      • Facial swelling and redness, especially in nose

    • Destruction of brain cells

      • Especially areas important to memory


    Fetal Alcohol Syndrome

    • Heavy alcohol intake during pregnancy

      • Fetal growth slowed

        • Cranial, facial and limb anomalies occur

    • Moderate alcohol intake

      • 1 drink per day

      • Learning and memory impairments

      • Growth deficits

    • Total abstinence recommended by NIAAA


    Nicotine and Cigarette Smoking

    • Nicotine

      • Addicting agent of tobacco

      • Principal alkaloid

        • Active chemicals that give drugs their physiological and psychological altering properties

      • Stimulates dopamine neurons in mesolimbic area

        • Involved in reinforcing effect


    Prevalence and Health Consequences

    • Prevalence decreased since mid 1960s although use increased through the 1990s, among white adolescents

    • More prevalent among white & Hispanic youth than African Americans

      • African Americans less likely to quit and more likely to get lung cancer

        • Metabolize nicotine more slowly

    • Chinese Americans have lower lung cancer rates

      • Metabolize less nicotine

    • More prevalent among men than women

      • Exception: 12 to 17 year olds

    • Secondhand smoke (ETS, environmental tobacco smoke)

      • Higher levels of ammonia, carbon monoxide nicotine and tar

      • Causes 40,000 deaths per year in US


    Marijuana

    • Drug derived from dried and ground leaves and stems of the female hemp plant (Cannibis sativa)

    • Hashish

      • Stronger than marijuana

      • Produced by drying the resin exudate of the tops of plants


    Prevalence

    • Most frequently used illicit drug in US

      • 15,000,000 reported using it in 2006

    • Peaked in 1979 then began to decline

      • Rose again in 90s

    • Greater use by men than women although rates among women increased faster in 1990s


    Effects of Marijuana

    • Major active ingredient

      • THC (delta-9-tetrahydrocannabinol)

    • Psychological

      • Feelings of relaxation and sociability

      • Rapid shifts of emotion

      • Interferes with attention, memory, and thinking

        • Decline in IQ over time

      • Heavy doses can induce hallucinations and panic

      • Impairment of skills needed for driving

        • Impairment present for several hours after ‘high’ has worn off

    • Physiological

      • Bloodshot & itchy eyes

      • Dry mouth and throat

      • Increased appetite

      • Reduced pressure within the eye

      • Increased BP

      • Abnormal heart rate

        • May exacerbate preexisting cardiovascular problems

      • Damage to lung structure and function in long term users


    Therapeutic Effects of Marijuana

    • Reduces nausea and loss of appetite caused by chemotherapy (Salan et al., 1975)

    • Relieves discomfort of AIDS (Sussman et al., 1996)

    • Analgesic effects due to ability of THC to block pain signals from reaching the brain.

    • Supreme Court rulings:

      • Federal law prohibits dispensing marijuana for medicinal purposes

      • Medical use can be prohibited by federal government even if states approve


    Opiates

    • Group of addictive sedatives that in moderate doses relieve pain and induce sleep

      • Opium

      • Morphine

      • Heroin

      • Codeine

    • Synthetic sedatives

      • Seconal and valium

    • Opiates legally prescribed as pain medications include:

      • Hydrocodone combined with other substances yields Vicodin, Zydone, and Lortab

      • Oxycodone the basis for OxyContin, Percodan, & Tylox.


    Prevalence of Opiate Use

    • Heroin

      • Estimated1,000,000 individuals addicted to heroin in US

        • 300,000 in 2006 alone

      • From 1995 to 2002, rates of use among adults 18 to 25 increased from 0.8% to 1.6%

      • Accounted for 62 to 82% of drug-related hospital admissions in Baltimore, Boston, & Newark.

    • Heroin is more pure (25 to 50%) than in the past

      • Increases likelihood of overdose

    • OxyContin prescriptions jumped 1800% between 1996 and 2000 (DEA, 2001)

      • 2.8 million users (SAMSHA, 2004)

        • Can be dissolved for injection or snorting

        • Street price from $25 to $40 per pill


    Psychological and Physical Effects of Opiates

    • Euphoria, drowsiness, reverie, and lack of coordination

      • Loss of inhibition, increased self-confidence

      • Severe letdown after about 4 to 6 hours

    • Heroin and OxyContin

      • Rush

        • Intense feelings of warmth and ecstasy following injection

    • Stimulate receptors of the body’s opioid system

      • Endorphins and enkephalins

    • Tolerance develops and withdrawal occurs

      • Muscle soreness and twitching, tearfulness, yawning

      • Become more severe and also include cramps, chills/sweating, increase in HR and BP, insomnia, & vomiting

        • Withdrawal lasts about 72 hours


    Psychological and Physical Effects of Opiates

    • 29 year follow up of 500 heroin addicts (Hser, et al., 1993)

      • 28% dead by age 40

        • Half by suicide, homicide, or accident

        • One-third by overdose

    • Many users resort to illegal activities to obtain money for drugs

      • Theft, prostitution, dealing drugs

    • Exposure to infectious diseases via shared needles

      • e.g. HIV

      • Evidence suggests that free needles reduces infectious diseases associated with IV drug use


    Synthetic Sedatives

    • Barbituates

      • Induce muscle relaxation, reduce anxiety, produce mild euphoria

      • In 1940s prescribed to aid sleep

      • Usage declined from 1975 thru 1990s but increased recently

    • Other synthetic sedatives

      • Benzodiazepines

        • e.g., Valium, Ketamine

    • Stimulate GABA system

    • Heavy dosages

      • Slurred speech

      • Unsteady gait

      • Impaired judgment & concentration

      • Irritability & combativeness

      • Accidental suffocation due to excessive relaxation of diaphragm muscles

    • Alcohol magnifies depressant effects

    • Tolerance & withdrawal

      • Delirium, convulsions & other symptoms


    Stimulants: Amphetamines

    • Increase alertness and motor activity

    • Reduce fatigue

    • Amphetamines

      • Synthetic stimulants

        • Benzedrine, Dexedrine, Methedrine

      • Trigger release of and block reuptake of norepinephrine and dopamine

      • Produce high levels of energy, sleeplessness

      • Reduce appetite, increase HR, constrict blood vessels in skin and mucous membranes

      • High doses can lead to:

        • Nervousness, agitation, irritability confusion, paranoia, hostility

      • Tolerance can develop after only 6 days use (Comer et al., 2001)


    Stimulants: Methamphetamine

    • Amphetamine derivative (aka crystal meth)

      • Can be taken orally, intravenously, or intranasally (snorting)

      • In 2006, over 700,000 people used methamphetamine (SAMHSA, 2007).

    • Chronic use damages brain

      • Reduction in hippocampus volume (see figure 10.4; abusers represented by yellow bars)


    Stimulants: Cocaine

    • Alkaloid obtained from coca leaves

      • Reduces pain

      • Produces euphoria

      • Heightens sexual desire

      • Increases self-confidence and indefatigability

    • Blocks reuptake of dopamine in mesolimbic areas of brain

    • Overdose

      • Chills, nausea, insomnia, paranoia, hallucinations; possibly heart attack & death

    • Not all users develop tolerance

      • Some become more sensitive

        • May increase risk of OD

    • In 2006, 2.4 million people over the age of 12 reported using cocaine, and 700,000 reported using crack (SAMHSA, 2007).


    Stimulants: Cocaine

    • Crack

      • Form of cocaine that quickly become popular in the 80s

      • Rock crystal that is heated, melted, & smoked

      • Cheaper than cocaine


    Hallucinogens, Ecstasy, and PCP

    • Hallucinogeneffects include:

      • Colorful visual hallucinations

      • Synestesias

        • Overflow from one sensory modality to another

      • Alterations in time perception

      • Lability of mood

      • Anxiety & paranoia

    • LSD

      • d-lysergic acid diethylamide

    • Psilocybin

      • Extracted from mushroom psylocube mexicana

    • Mescaline

      • Active ingredient of peyote

    • Ecstasy

      • Increase feelings of intimacy and enhances mood

      • Chemically similar to mescaline and amphetamines

    • PCP (phencyclidine)

      • Angel dust

      • Animal tranquilizer

      • Causes severe paranoia and violence


    Figure 10.5 Process of Becoming a Drug Abuser


    Etiology of Substance-Related Disorders: Developmental approach

    • Li et al. (2001) Two paths to alcohol abuse

      • First group began drinking in early adolescence, increased drinking throughout high school

      • Second group drank lesser amounts in early adolescence, increased drinking in middle school and again in high school.

        • Boys more likely to be in the first group, girls in the second group

    • Developmental studies do not account for all cases

      • Not an inevitable progression through stages


    Etiology of Substance-Related Disorders:Genetic Factors

    • Relatives and children of problem drinkers have higher-than-expected rates of alcohol abuse or dependence

    • Greater concordance in MZ than DZ twins

      • In men

        • Alcohol, caffeine, smoking, marijuana, & drug abuse in general

      • In women

        • Role of genetics less clear

        • Fewer available studies

        • Findings are mixed

    • Genetic and shared environmental risk factors for illicit drug abuse and dependence appear to be nonspecific

    • Ability to tolerate large quantities of alcohol may be an inherited diathesis

      • Asians have low rates of alcohol abuse

    • CYP2A6

      • Gene associated with metabolism of nicotine

      • Smokers with defect in this gene less likely to become dependent (Rao et al., 2000)


    Etiology of Substance-Related Disorders: Neurobiological Factors

    • Nearly all drugs, including alcohol, stimulate the dopamine system in the brain

    • Some evidence that people dependent on drugs or alcohol have a deficiency in the dopamine receptor DRD2

    • People take drugs to avoid the bad feelings associated with withdrawal

      • Explains frequency of relapse

    • Incentive-sensitization theory (Robinson & Berridge, 19983, 2003)

      • Distinguish

        • Wanting (craving for drug)

        • Liking (pleasure obtained by taking the drug)

      • Dopamine system becomes sensitive to the drug and the cues associated with drug (e.g., needles, rolling papers, etc.)

      • Sensitivity to cues induces & strengthens wanting

    • Brain imaging studies show that cues for a drug (needle or a cigarette) activate the reward and pleasure areas of the brain involved in drug use.


    Etiology of Substance-Related Disorders: Psychological factors

    • Mood alteration

      • Tension reduction may be due to “alcohol myopia” (Steele & Joseph, 1990)

        • User focuses reduced cognitive capacity on immediate distractions

        • Less attention focused on tension-producing thoughts

      • Effect similar for smoking

      • Cognitive distraction also reduces aggressive behavior in intoxicated individuals

      • However, alcohol and nicotine may increase tension when no distractions are present.

    • Expectancies about drugs effects influence behavior

      • People who expect alcohol to reduce stress & anxiety are most likely to drink

      • The greater perceived risk, the less likely it is to be used


    Etiology of Substance-Related Disorders: Psychopathology and Personality

    • Personality factors that predict onset of substance related disorders:

      • Negative emotionality

      • Desire for increased arousal and positive affect

      • Constraint

        • Harm avoidance, conservative moral values, & cautious behavior

    • Kindergarten children who were rated high in anxiety and novelty seeking more likely to get drunk, smoke, and use drugs in adolescence.


    Etiology of Substance-Related Disorders: Sociocultural factors

    • Alcohol is the most common abused substance worldwide (Smart & Ogborne, 2000)

    • Men consume more alcohol than women but differences vary by country

      • Israel

        • Men drank 3x as much as women

      • Netherlands

        • Men drank 1½x as much as women

    • Availability

      • Usage is higher when alcohol and drugs are easily available


    Etiology of Substance-Related Disorders: Sociocultural factors

    • Family factors

      • Parental alcohol use (Hawkins et al., 1997)

      • Psychiatric, marital, or legal problems in the family linked to drug abuse

      • Lack of emotional support from parents increases use of cigarettes, marijuana, and alcohol (Cadoret et la., 1995a)

      • Lack of parental monitoring linked to higher drug usage (Chassin et al., 1996; Thomas et al., 2000)


    Etiology of Substance-Related Disorders: Sociocultural factors

    • Social network

      • Social influence or social selection?

      • Bullers et al.(2001) found evidence for both

        • Having peers who drink influences drinking behavior (social influence) but individuals also choose friends with drinking patterns similar to their own (social selection)

    • Advertising and Media

      • Countries that ban ads have 16% less consumption than those that don’t (Saffer, 1991)


    Treatment of Substance Related Disorders: Alcohol Abuse and Dependence

    • Inpatient hospital treatment

      • Detoxification

        • Withdrawal from alcohol under medical supervision

        • The therapeutic results of hospital treatment are not superior to those of outpatient treatment

    • Alcoholics Anonymous (AA)

      • Largest self-help group for problem drinkers

      • Regular meetings provide support, understanding, and acceptance

      • Promotes complete abstinence

      • Although some studies have shown AA participation predicts better outcome, recent studies suggest AA no more effective than other forms of therapy.


    Treatment of Substance Related Disorders: Alcohol Abuse and Dependence

    • Couples and Family Therapy

      • Emphasizes support from problem drinker’s partner

      • Reduced problem drinking maintained1 year after therapy ended

      • Also reduced couples’ overall level of distress


    Treatment of Substance Related Disorders: Alcohol Abuse and Dependence

    • Cognitive and Behavioral Treatments

      • Contingency-Management Therapy

        • Patient and family reinforce behaviors inconsistent with drinking

          • e.g., avoiding places associated with drinking

        • Teach problem drinker how to deal with uncomfortable situations

          • e.g., refusing the offer of a drink

        • AKA Community-reinforcement approach

      • Relapse Prevention

        • Strategies to prevent relapse

      • Brief motivational interventions

        • Designed to curb heavy drinking in college


    Treatment of Substance Related Disorders: Alcohol Abuse and Dependence

    • Controlled drinking

      • Belief that problem drinkers can consume alcohol in moderation

      • Avoid total abstinence and inebriation

      • Guided self-change

    • Medications

      • Antabuse (disulfiram)

        • Produces nausea and vomiting if alcohol is consumed

      • Other medications include naltrexone, naloxone, & acamprosate

        • Most effective when combined with CBT


    Treatment of Substance Related Disorders: Nicotine Dependence

    • Peer behavior important

      • If others in social network stop smoking, increases likelihood that individual will also stop

    • Rapid smoking treatment

      • Rapid puffing, focused smoking, & smoke holding

    • Scheduled smoking

      • Reduce nicotine intake gradually over a few weeks

    • Physician’s advice

      • By age 65, most smokers have quit (USDHHS, 1998b)

    • Nicotine replacement treatments

      • Gum, patches, or inhalers

      • Reduce craving for nicotine

      • Combining patch with antidepressants improved success rate


    Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence

    • Detoxification central to treatment

    • Psychological treatments

      • Desipramine and CBT showed effectiveness for cocaine use

        • CBT especially helpful for users with high dependence levels (Carroll et al., 1994, 1995)

      • Operant conditioning

        • Tokens that can be traded for desirable goods are given to users who abstain (Dallery et al., 2001)

      • Motivational interviewing or enhancement thereapy

        • CBT plus Rogerian therapy effective for alcohol and drug use (Burke et al., 2003)

      • Self-help residential homes for heroin users

        • Non-drug environment

        • Group therapy

        • Guidance and support from former users


    Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence

    • Drug replacement treatments and medications

    • A meta-analysis of stimulant medication as a treatment for cocaine abuse revealed little evidence that this type of medication is effective

    • Heroin replacements

      • Synthetic narcotics

        • Methadone, levomethadyl acetate, bupreophine

        • Used to wean heroin users from dependence

      • More effective if combined with psychological support & treatment (Lilley et al., 2000)


    Prevention of Substance-Related Disorders

    • Often aimed at adolescents

    • Utilize some or all of the following elements:

      • Enhancing self-esteem

      • Social skills training

      • Peer pressure resistance training

      • Parental involvement in school programs

      • Warning labels on alcohol bottles

      • Education regarding alcohol impairment

      • Testing for drugs and alcohol at school or work


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