CHAPTER 7 ADDICTIVE BEHAVIOURS

1. CHAPTER 7ADDICTIVE BEHAVIOURS

2. Aims and Objectives Provide diagnostic criteria for substance use disorders and pathological gambling Review information regarding prevalence, age of onset, course, and problems associated with these disorders Discuss current biopsychosocial perspectives on aetiology Describe treatments for addictive behaviours

3. Addictive behaviours The diagnosis of substance use disorders Substance dependence Current DSM criteria includes complex cluster of cognitive/psychological, behavioural, and physiological symptoms occurring for at least 12 months Withdrawal - symptoms that occur when an individual stops using substance Alcohol: autonomic hyperactivity, nausea/vomiting, shakiness Opioids: nausea/vomiting, diarrhoea, insomnia, muscle aches Stimulants: fatigue, sleep disturbances, psychomotor agitation/retardation Substance abuse Substance problems that do not meet for dependence Maladaptive pattern of substance use that results in considerable impairment in functioning or distress over 12 month period

4. Addictive behaviours Epidemiology of substance use disorders Prevalence Alcohol most commonly used drug in Australia 10% of population meet for harmful use or dependence Substance use disorders diagnosable in an additional 1.6% Age of onset and course Disorders predominantly of the young, decrease in prevalence with age High rates of mortality from excessive use of alcohol from accidents, violence, and suicide, as well as medical complication such as liver cirrhosis Drug abuse and dependence a leading cause of death of young people from trauma, suicide, overdose and infectious disease such as HIV

5. Addictive behaviours Aetiology of substance use disorders Impaired control versus choice theories Disease Model of Addiction describes addiction as a medical disorder characterised by brain impairment In contrast, other models suggest that the maladaptive use of substance reflects a rational choice (Skog, 2000) Biological factors Substance use disorders tend to cluster in families Adoption and twin studies also support genetic factors The genetic basis of substance use disorders is thought to be non-specific Addictive substances act on the brains reward systems Dopaminergic reward system thought to be most important Endogenous opioid system Inhibition Dysregulation Theory- impairment of inhibitory system

6. Addictive behaviours Aetiology of substance use disorders Psychological factors: behavioural theories Instrumental or Operant Learning Model Positive reinforcement = experience of pleasure Negative reinforcement = alleviation of symptoms of withdrawal Opponent-process Theory of Addiction – feedback loop Classical conditioning – unrelated stimuli become associated with drug Incentive-Sensitisation Theory – drugs change the area of the brain responsible for the incentive to use drugs Psychological factors: personality theories Cloninger’s Tri-Dimensional Personality Theory Novelty seeking, harm avoidance, reward dependence

7. Addictive behaviours Aetiology of substance use disorders Psychological factors: cognitive theories Outcome Expectancy Theory – individuals’ expectations of positive consequences from substance use increase propensity to use Beck’s Cognitive Theory of Substance Use – network of maladaptive beliefs Relapse Prevention Theory – individuals in high-risk situations will relapse if they do not have coping strategies, self-efficacy, etc. Social and cultural factors Familial influences Family functioning – ineffective parenting, negative communication patterns Parental modelling of their own substance use Peer influences Cultural influences – availability, cost, and social acceptability of substance

8. Addictive behaviours Treatment of substance use disorders Detoxification Not a treatment, but may be a useful first step Appropriate therapeutic goals Abstinence versus controlled use Controlled drinking may be an appropriate goal for some patients Motivational enhancement therapy (Miller & Rollnick, 2002) Used for individuals with low motivation to change Based on Stages of Change model (Prochaske & DiClemente, 1986) Brief and early interventions Limited contact with health professional Assessment, feedback, and educational material Found to be beneficial for use of alcohol, amphetamines and cannabis

9. Addictive behaviours Treatment of substance use disorders Skills training approaches Communication skills, problem-solving, assertiveness skills, relaxation and stress management skills have all been effective for alcohol problems Pharmacological interventions Block rewarding effects of the substance (e.g., naltrexone) Used as a less-harmful substitute (e.g., methadone) Reduce severity of withdrawal symptoms (e.g., nicotine patch) Relapse prevention Importance of anticipating high-risk situations Continuing to develop coping skills Comorbid psychological disorders High comorbidity with other mental disorders Must target these disorders during treatment

10. Addictive behaviours Definition of pathological gambling 3 categories of gambling: gaming, wagering and lotteries People are motivated for entertainment and to win money Types of gamblers Social, non-problem gamblers – gambling within affordable limits Problem gambling – characterised by difficulties limiting money and/or time spent on gambling, which leaves to adverse consequences Pathological gambling – severe end of the problem gambling spectrum, impaired control manifested by repeated, failed attempts to stop or reduce gambling despite significant negative consequences Historical approaches Gambling and gaming have existed since antiquity Interest in problem gambling began with psychoanalytic movement First classified as a psychological disorder in DSM-III (1980)

11. Addictive behaviours Diagnostic criteria for pathological gambling DSM-IV-TR defines pathological gambling as persistent and recurrent maladaptive gambling behaviour indicated by at least 5 of the following: 1. The individual is preoccupied with gambling 2. The individual needs to gamble with increasing amount of money 3. The individual has made repeated unsuccessful attempts to cut down or stop 4. The individual is restless or irritable when attempting to quit 5. The individual gambles as a way to escape problems or negative mood 6. After losing money, the individual returns to get even, referred to as “chasing” 7. The individual lies to others to conceal extent of gambling 8. The individual has committed illegal acts to finance gambling 9. The individual lost/jeopardised significant relationship, job, etc. 10. The individual relies on others for money for a desperate financial situation Diagnostic criteria for pathological gambling similar to substance dependence, but pathological gambling is classified as an impulse control disorder

12. Addictive behaviours Is pathological gambling an addiction? Phenomenological similarities between gambling and substance use problems led to Addiction Model of gambling Gambling is conceptualised as an addiction on the basis that individuals repeatedly engage in a behaviour to achieve a euphoric state Repetitive nature, loss of control, tolerance and withdrawal similar to drug addiction However, some differences between gambling and substance dependence Withdrawal symptoms following cessation of gambling are mild and psychological (e.g., irritability, poor concentration, depressed mood) Substances (unlike gambling) acts directly on the brain’s reward pathways

13. Addictive behaviours Epidemiology of problem gambling Among adolescents, 5% meet criteria for pathological gambling Among Australian adults, 2.1% prevalence (1% internationally) Males gamble more frequently and intensely than females For less severe cases, problem gambling may be transitory Several phases proposed by Robert Custer (1984): Winning phase – motivated by excitement Losing phase – attempt to recoup loses Desperation phase – engage in illegal activities to survive Course of disorder influenced by comorbid psychological disorders (e.g., 75% of gamblers suffer major depression)

14. Addictive behaviours Aetiology of pathological gambling Complex interaction of biological, psychological, sociocultural factors Biological factors Serotonin – involved in specific impulsive behaviours and may play a role Dopamine – associated with impulsive-addictive behaviours, the D2 receptor gene may be involved Norepinephrine – involved with arousal excitement, impulsive behaviour, and sensation seeking. May be a causal factor

15. Addictive behaviours Aetiology of pathological gambling Psychological factors Personality Impulsivity – elevated levels associated with gambling Sensation seeking – relationship with gambling unclear Majority of pathological gamblers have at least 1 personality disorder Learning Operant (instrumental) conditioning Schedule of reinforcement – intermittent and unpredictable wins produce behaviours that are highly resistant to extinction Classical conditioning – gambling-related environmental cues paired with arousal. Exposure to cues leads to urge to gamble Cognitions Erroneous beliefs lead individuals to overestimate their chances of winning

16. Addictive behaviours Aetiology of pathological gambling Social and cultural factors Parental modelling of positive attitudes toward gambling Early negative childhood experiences Availability of gambling Social attitudes encouraging gambling Exposure model - as gambling opportunities increase within a community, shifts in attitudes occur, and there will be more gambling Integrated pathways model (Blaszczynski & Nower, 2002) -incorporates biological, personality, learning, cognitive, social and cultural factors in differentiating three subgroups of problem gamblers Behaviourally conditioned problem gamblers Emotionally vulnerable problem gamblers Biologically based problem gamblers

17. Addictive behaviours Treatment of pathological gambling Gamblers’ Anonymous – self-help organisation, 12-step recovery process derived from the principles and format of Alcoholics Anonymous Behavioural and cognitive interventions Behavioural interventions Counter-condition the arousal (aversion therapy) Extinguish arousal to gambling cues (exposure therapy Cognitive behavioural treatments Challenging dysfunctional beliefs plus behavioral techniques Pharmacological interventions SSRIs, opioid antagonists, and mood stabilisers The public health model Concerned with external societal determinants of gambling Reduce population-based risk factors, promote responsible gambling

18. Summary Substance Use Disorders Diagnosis Epidemiology Aetiology Treatment Pathological Gambling Definition, Types of Gamblers, and Historical Approaches Diagnostic Criteria Is Pathological Gambling an Addiction? Epidemiology Aetiology Treatment