Substance-Related and Impulse Control Disorders

1. Substance-Related and Impulse Control Disorders

2. Levels of Involvement – Substance Disorders Terminology • Rate of use illegal substances: 8% • Specific drugs have specific effects, but terminology applies to all

3. Psychoactive substances: alter mood or behavior • Substance use: moderate ingestion of psychoactive substances, does not interfere with functioning

4. Intoxication • Intoxication: physiological reactions resulting from ingestion of psychoactive substance • Impaired judgment • Changes in motor ability • Mood changes

5. Substance Abuse • Substance abuse: pattern of substance use that leads to significant distress or impairment in roles, and in hazardous situations

6. Substance Dependence • Substance dependence: characterized by need for increased amounts to achieve desired effect (tolerance) • Negative physical effects when withdrawn (withdrawal)

7. Substance Dependence • Dependence is also marked by: • Unsuccessful attempts at control • Substantial effort expended to seek • Substantial effort to recover

8. TAKES more than intended WANTS to cut back, but has failed SPENDS lots of time trying to get or do OFTEN intoxicated or in withdrawal CURTAILS other activities USES substance despite problems it causes NEEDS more and more of substance to achieve effect SUFFERS withdrawal TAKES substance to avoid withdrawal Psychiatric Definition – 3 of 9 required for addiction

9. Relative Addictiveness Based on Expert Ratings

10. Diagnostic Specifics • Diagnoses are given by • Substance • Dependence, abuse, intoxication, withdrawal • Other disorders can complicate picture

11. Individual Substances • Depressants: sedation, relaxation. Include alcohol, sedative drugs • Stimulants: increase activity, alertness, mood. Amphetamines, cocaine, nicotine, caffeine • Opiods: reduce pain and increase euphoria. Heroin, opium, morphine • Hallucinogens: alter sensory perception. Marijuana, LSD

12. Depressants • Alcohol • Sedatives

13. Alcohol Abuse • 23% Americans binge drink (5+) • 15 million Americans are alcohol dependent • Very culturally dependent • Peru: 25% • Shanghai: 0.45% • Dependency is chronic • Earlier age (11-14) = increased risk disorder

14. Sedative Use Disorders • Calming, sleep-inducing, anxiety reducing • Barbituates ↓ • Common use for suicide (suffocation) • Benzodiazepines ↑ • Less than 1% of treatment seekers

15. Description & Effects of Alcohol • Initial depression of inhibitory centers • Spreads to motor coordination, reaction time, judgments, etc • Withdrawal can be severe • Hand tremors, nausea & vomiting, anxiety, hallucinations, insomnia, agitation, delirium • Long-term abuse can lead to dementia

16. Stimulants • Amphetamines • Cocaine • Nicotine • Caffeine

17. Amphetamine Use Disorders • Elation → Crashing • Man-made • asthma, nasal decongestant • Weight loss, narcolepsy, ADHD

18. Diagnostic criteria • Behavioral symptoms • Changes in affect • Sociability, interpersonal sensitivity • Anxiety, anger • Impaired judgment • Quick tolerance

19. Cocaine Use Disorders • Short-lived high, paranoia is common (2/3) • Dependence is different • Inability to resist increases • Few early negative effects • Lack of sleep, paranoia • Withdrawal leads to severe apathy

20. Opiods • Natural, synthetic, endogenous to body • Euphoria, drowsiness, slowed breathing • Analgesics (e.g., morphine) • Very unpleasant withdrawal • 6-12 hours • Yawning, nausea, vomiting, chills, muscle aches, diarrhea, insomnia (1-3 days) • Poor prognosis

21. Hallucinogens (LSD) • Synthetically produced • Quick tolerance • Lack of effect over days • Little reported withdrawal • Mechanism unknown • Long-term effects unknown

22. Other Substances of Abuse • Inhalants • Most common poor adolescent males • Steroids • “Designer drugs”

23. Causes of Substance Abuse Disorders • Biological Factors • Genetic • Neurobiological • Psychological Factors • Reinforcement • Cognitive Factors • Social Factors • Culture • Integrative Model

24. Biological Influences - Genes • Drug abuse (particularly alcohol) have genetic influence • Easiest to study alcohol • Common genetics? • Use = environment, abuse = genetic?

25. Biological Influences - Neurobiology • Positive reinforcement of natural pleasure states neurologically • Dopaminergic system + opiods • How does negative reinforcement work?

26. Psychological Influences – Positive and Negative Reinforcement • Positive reinforcement can be physical • Also social • Negative reinforcement = relief (Such as anxiety, pain, etc.) • Used to “self medicate”

27. Cognitive Factors • Expectancy effects • Predict future drinking use by teens • Drinking will improve social behavior, motor, and cognitive abilities • Expectancies might result from us • Cravings • Influenced by cognitions – availability, environment, moods

28. Social Factors • Exposure to substances influences disorder development • Media exposure, peer exposure • Less monitoring by parents with disorder

29. Cultural Influences • Cultural expectations for drug use • Economic influences

30. An Integrative Model • Textbook p. 415 • All influences work together to increase likelihood of substance disorder • Also influences the maintenanceof that disorder • Equifinality: a particular disorder can arise from multiple and different paths

31. Treatment of Substance-Related Disorders • Personal motivation is essential • Difficult and slow • Individualized • Treatments across type of drug very similar • Biological Treatments • Psychosocial Treatments

32. Biological Treatments – Agonist Substitution • Patient is provided with safe drug that has similar chemical makeup • E.g. methadone (opiod) for heroin • No high, but same analgesic and sedation • Results are mixed • Cross-tolerance • Abuse of other drugs • Lifelong dependency

33. Biological Treatments – Antagonist Treatment • Effects of drug are blocked, so no longer produce pleasant results • Naltrexone – produces immediate withdrawal symptoms from opiods • Might also help with alcoholism, with therapy

34. Biological Treatments – Aversive Treatment • Make ingesting psychoactive drug unpleasant • Associate drug use with side effects • Antabuse • Nausea, vomiting, elevated heart rate, respiration • Noncompliance is large problem

35. Psychological Treatments • Inpatient treatment • Alcoholics Anonymous (and variants) • Controlled Use • Component Treatment • Relapse Preventions

36. Inpatient Treatment • Help addicts through initial withdrawal • Expensive • May be no difference between inpatient and outpatient care • Environment is different

37. Alcoholics Anonymous • Developed 1935 • Alcoholism as a disease that requires lifelong management • High levels of social support • 97,000 groups in 100 countries • 3% of Americans report attending at least 1 meeting in their lifetime • Relies on prayer and belief in higher power • Research on AA is very difficult

38. Controlled Use • Alternative to total abstinence • Some may become social users • Extremely controversial • both controlled use and abstinence is successful for only 20-30% of patients

39. Component Treatment • Aversion therapy – use paired with punishment • Covert sensitization • Contingency management – rewards • Community reinforcement – address life • Close other participates • Identify antecedents and consequences • Assistance with social services • New recreational activities

40. Relapse Prevention • Learned aspects of dependence • Relapse = failure of cognitive and behavioral coping skills • Target ambivalence • Positive aspects • Negative consequences • Identify high risk situations and plan

41. Impulse-Control Disorders • Intermittent Explosive Disorders • Kleptomania • Pyromania • Pathological Gambling • Trichotillomania • Problematic Internet Use

42. Intermittent Explosive Disorder • Aggressive impulses • Result in serious assault or destruction of property • Rarely diagnosed • Symptoms often accounted for by another disorder

43. Kleptomania • Urges to steal things • Not needed for personal use or monetary value • Rare? (Difficult to study) • Urge brings sense of tension, which is relieved by stealing

44. Pyromania • Urge to set fires • Pattern similar to kleptomania (tension & relief) • Less than 4% of arsonists • Very little research

45. Pathological Gambling • Increasing number of patients • 3-5% of adult Americans • Increasing among adolescents • Similar criteria to substance abuse • Increasing amounts for “high” • Withdrawal • Interference with functioning

46. Pathological Gambling • fMRIs show decreased activation in regions of brain that regulate impulses, while gambling • Abnormalities in dopamine and serotonin • Gambler’s Anonymous • 70-90% drop out • Need high motivation

47. Trichotillomania • Urge to pull out one’s hair • 1-5% of college students • Greater incidence in females • Antidepressants & Cognitive therapy seem to have effect • Research is very scarce

48. Internet Addiction • Excessive gaming, sexual preoccupation, and/or email/text use • Excessive Use • Loss of time, neglect of basic drives • Withdrawal • Anger, tension, depression when inaccessible • Tolerance • Better equipment, new software, longer times • Negative Repercussions • Lying, arguments, academic achievements, social isolation

49. Internet Addiction • Difficult to research • In US, Internet and computers are accessed from home • 86% estimated to have comorbidity • Shame, denial, motivation, lack of awareness • Estimated 0.3-0.7% prevalence in US