ABNORMAL PSYCHOLOGY PSYC 385
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Chapter 9 Substance Use Disorders Researchers define addiction as the compulsion to seek and then use a psychoactive substance either for its pleasurable effects or with continued use for relief from negative emotions such as anxiety or stress The DSM definition of substance abuse focuses on the behaviors related to obtaining and using a drug as well as the consequences of that use Intoxication refers to the direct results of using a substance substance abuse focuses more on the indirect effects of repeated use According to the DSM patients cannot be diagnosed with both substance abuse and substance dependence patients who meet the criteria for both disorders are only diagnosed with substance dependence People can develop substance abuse in 3 ways First substance abuse can arise unintentionally as can occur through environmental exposure Consider a gas station attendant who daily inhales gasoline fumes Second substance abuse or dependence can develop when the psychoactive element is a side effect and the substance is taken for medicinal reasons unrelated to the psychoactive Third substance abuse can develop as a result of the intentional use of a substance for its psychoactive effect as the Beatles did Initiation gt Experimentation gt Casual Use gt Regular Use gt Abuse gt Dependence Two factors are associated with progressing from using drugs to using hard drugs 1 Age The younger a person is when he or she starts to use drugs or alcohol the more likely he or she will be to abuse drugs later in life N Quantity The more drugs a person uses at the onset the more likely he or she is to continur along the road to substance dependence Substance use abuse and dependence may be better conceptualized as occurring on a continuum rather than as discrete categories Where an individual s use falls on the continuum would be determined by frequency quantity and duration Common comorbid disorders include mood disorders most frequently depression posstraumatic stress disorder schizophrenia and ADHD Substance abuse and dependence are among the more common psychological disorders Men are more likely to be diagnosed with a substance abuse or dependence disorder although women are more likely to be diagnosed with abuse of or dependence on legally obtained prescription medications Asian Americans have the lowest rates of alcohol abuse or dependence whereas Native Americans have the highest rate Although African American s are more likely to abuse or be dependent on illegal substances they are 2nd least likely to be diagnosed Patterns of use Abstinence ex Muslim societies Constrained ritual use of alcohol ex Among religious Jews Drinking as a common activity ex As in some Mediterranean cultures PPN quotFiestaquot drunkenness during community celebrations Stimulates are named for their effect on the central nervous system they stimulate it causing activity and arousal Examples of stimulants nicotine amphetamines cocaine crack and ecstasy At low doses a stimulant can make the user feel alert less hungry and more energetic mentally and physically Hallucinations caused by cocaine occur because cocaine causes sensory neurons to fire spontaneously Dependence on cocaine may take months or even years to develop dependence on crack can develop extremely rapidly within weeks Crack use is associated with the most rapid progression to dependence Common amphetamines include Benzedrine Dexedrine and Adderall Amphetamine psychosis a condition characterized by paranoid delusions and hallucinations With repeated use of amphetamines people may become hostile toward others or develop a sense of grandiosity as well as exhibit disorganized thinking or behavior Withdrawal symptoms may include depression fatigue anxiety and irritability Methamphetamine is chemically similar to amphetamines but has a greater and longer lasting effect on the central nervous system Meth can lead to an intense rush of pleasure Meth can cause irritability heart problems hallucinations and paranoia at high doses Ritalin those who abuse Ritalin take the substance in any of the 3 ways 1 swallowing pills which does not usually lead to dependence 2 inhaling or snorting crushed pills which leads to a quicker high and causes increased heart rate stroke or lung problems 5 injecting the drug in liquid form which is reported to produce an effect similar to that of cocaine Both inhaling and injecting Ritalin can lead to dependence MDMA Ecstasy Abuse can result in poor mood and difficulty regulating emotions as well as anxiety and aggression sleeping problems and decreased appetite Users can also develop impaired cognitive functioning especially problems with memory after the drug wears off The effects of MDMA may be difficult to predict in part because the tablets often contain other drugs such as ketamine cocaine or other stimulates MDMA binds to serotonin transporters and thereby creates excess serotonin in the synapse This excess serotonin can have a calming effect Nicotine the active ingredient in tobacco is a stimulant that leads to abuse and dependence and tobacco use is associated with cancer Withdrawals include symptoms often include insomnia anxiety irritability and concentration problems Nicotine acts on a specific type of acetylcholine receptor call the nicotinic receptor Such receptors are located on cell bodies of dopaminereleasing neurons Activation of these receptors leads to increased release of dopamine in the nucleus accumbens as well as removing the inhibiting effect of other neurotransmitters According to the NIDA tobacco abuse and dependence is the number one preventable cause of death in the US Dopaminergic Hypothesis of substance abuse the rewarding effects of a drug arise directly or indirectly from the dopamine reward system People with fewer dopamine receptors are more vulnerable to drug use The smaller quantity of receptors means they have reduced activation in the reward system which is boosted by substance use Connections among the amygdala and hippocampus store associations between drug use and the stimuli related to drug use Simply perceiving such aspects of the environment can activate structures in the limbic system which is tightly tied to the DRS For example one structure is the anterior cingulate which was found that it was activated when cocaine addicts simply watched videotapes of cocaine related objects or events Stimulants lead to increased dopamine production in the nucleus accumbens and the higher level of dopamine not only has direct effects on the reward value of drugs but also indirectly modulates the activity of the GABAnergetic glutamate and serotonin systems Observational Learning through observations of others people develop expectations about when to use drugs and what the experience of using should be like Classical conditioning stimuli associated with drug use elicit a craving for the drug Create feedback loop Psychological factors related to substance use disorders include learning operant reinforcement of the effects of the drug classical conditioning of stimuli related to drug use which leads to cravings and observational learning of expectancies about both the effects of drugs and use of them to cope with problems Social factors related to substance use disorders include the specific nature of an individual s relationships with family members socioeconomic factors and cultural and perceived norms about N r and W use of DEPRESSANTS Depressants include alcohol opiates barbiturates and benzodiazepines such as Valium Native Americans have the highest prevalence of alcohol abuse and dependence and blacks are 40 less than whites to develop alcohol abuse BAC affected by the number of drinks consumed the period of time over which they were consumed the time since the individual has last eaten the individual s body weight and their gender Binge drinking or heavy episodic drinking occurs when a person drinks until his or her BAC reaches at least 08 in a 2 hour period Alcohol dependence is marked by four symptoms craving loss of control physical dependence PPN tolerance Sedativehypnotic drugs reduce pain and anxiety relax muscles lower blood pressure slow breathing and heart rate and induce sedation and sleep Drugs in this class barbiturates and benzodiazepines cause disinhibiting and depressant effects similar to those of alcohol Benzodiazepines barbiturates and alcohol directly affect the GABAnergic system which is widespread in the brain and primarily activates inhibitory neurons The resulting inhibition affects neurons in brain structures that are involved in anxiety such as the amygdala Chronic use of alcohol stimulates the production of a type of neurotransmitter called endogenous opioids pleasure chemicals is used to distinguish the neurotransmitter opioids from the feeling that occurs when someone has pushed themselves to physical limit and experiences deep pleasure In chronic drinkers the activity of endogenous opioids occurs only in response to alcohol Alcohol malnourishment can include a deficiency to vitamin 31 which eventually causes several parts of the brain to atrophy including the mammillary bodies and the thalamus important in storing new info Cirrhosis scar tissue development on the liver from excessive drinking over a long period of time We get hangovers because dehydration and the liver is working hard to remove toxin The liver relies on a 2 step process to break down alcohol 0 1 The liver converts alcohol into a substance called acetaldehyde chemical that is related to formaldehyde which is another toxin 0 2 It converts acetaldehyde to acetate which is harmless Continued use of depressants leads to tolerance and 39 Some are 39 quot lethal Depressants indirectly activate the dopamine reward system Psychological factors related to depressant abuse and dependence include observational learning to expect specific effects from depressant use and to use depressants as a coping strategy positive and negative reinforcement of the effects of the drug and classical conditioning of drug cues that lead to cravings Social factors related to abuse of and dependence on depressants include the nature of an individual s relationships with family members peers use of depressants norms and perceived norms about and N r useof r and factors III OTHER ABUSED SUBSTANCES o Narcotic Analgesics o Hallucinogens o Dissociative Anesthetics Narcotic Analgesics are derived from the opium poppy plant or chemically related substances NA are sometimes referred to as opiates or opioids Often referred to as exogenous opioids exogenous means arising from an outside source Exogenous opioids include methadone and heroin as well as codeine morphine and synthetic derivatives found in prescription pain relief such as I I I I 1 quot5 I and I Legal narcotics are often prescribed for persistent coughing severe diarrhea and severe pain Narcotics depress the CNS and can cause drowsiness and slower breathing which can lead to death if a NA is taken with a depressant Withdrawal begins 8 hours after the drug was last used include nausea and vomiting muscle aches tearing from the eyes dilated pupils sweating fever diarrhea and insomnia Heroin one of the stronger opioids and very addictive Tolerance is easily developed and withdrawal can happen within a few hours of last dose peak at 72 hours and subside within a few weeks Heroin slows down activity in the CNS t directly affects the part of the brain involved in breathing and coughing Heroin binds to opioid receptors in the brain which has the effect of decreasing pain and indirectly activates the dopamine reward system Continued use decreases the production of endorphins which act as a natural painkiller Opioids such as heroin bind to the same receptors as endorphins do Thus heroin abuse reduces the body s natural pain relieving ability Heroin dependence is often treated with methadone a synthetic opiate that binds to the same receptors as heroin Snorting pills gt injection under skin skin popping gt injection into blood vessels mainlining Hallucinogens substances that induce sensory or perceptual distortions hallucinations in any of the senses o LSD a synthetic hallucinogen Synesthesia blending of senses At higher doses can lead to delusions and distortions of time Has an effect within 30 to 90 minutes of being ingested and lasts 12 hours Effects can be unpredictable A bad trip can include intense anxiety fear and dread OOOOP feeling of losing control going crazy or dying O 2 after effects include psychosis hallucinations and visual disturbances and quotflashbacksquot termed hallucinogen persisting perception disorder in DSM which are involuntary and vivid memories of sensory distortions that occurred under the influence of drugs Recurrent use can lead to tolerance but disappears if the user stops the drug and LSD 0 does not cause withdrawal symptoms 0 Mescaline a psychoactive substance produced by some kinds of cacti o Psilocybin a psychoactive substance present in psilocybin mushrooms commonly referred to as magic mushrooms 0 Marijuana the dried leaves and flowers of the hemp plant cannabis sativa o The resin from the hemp plaints flowering top is made into another more potent drug hashish The active ingredient of marijuana and hashish is tetrahydrocannabinol THC Users cognitive and motor abilities are slowed or temporarily impaired THC ultimately activates the dopamine reward system Effects depend on the users mood expectations and environment 000 User who develops abuse or 39 I 39 will I 39 39 39 39 39 I I after he or she stops using Symptoms include irritability anxiety depression decreased appetite and disturbed sleep Chronic use adversely affects learning memory and motivation O 0 Associated with increased risk of heart attack THC is chemically similar to the type of neurotransmitters known as cannabinoids and it activates the dopamine reward system People who begin abusing marijuana at an early age have atrophy of brain areas that contain many receptors for cannabinoids especially the hippocampus and the cerebellum Atrophy of the hippocampus can explain why chronic marijuana users develop memory problems and atrophy of the cerebellum explain why they develop balance and coordination problems Dissociative Anesthetics produces a sense of detachment from the users surroundings a dissociation Anesthetic in the name reflects the fact that many of these drugs were originally developed as anesthetics to be used during surgery DA act like depressants and also affect glumate activity These drugs can distort visual and auditory perception Known as quotclub drugsquot The most commonly abused are phencyclidine and ketamine Phencyclidine PCP 0 Known as angel dust and rocket fuel 0 Can be snorted ingested or smoked o Abusers may report feeling powerful and invulnerable while the drug is in their system and they may become violent or suicidal Memory speech and cognitive problems can arise within a year of last use 0 Medical effects of high doses include a decrease in breathing and heart rates dizziness nausea and vomiting seizures coma and death Users may experience hallucinations delusions paranoia disordered thinking 0 Medical effects of low dose include increased blood pressure heart rate and sweating coordination problems and numbness in hands and feet Ketamine o Aka Special K or vitamin K o Induces anesthesia and hallucinations and can be injected or snorted o Chemically similar to PCP but is shorter acting and has less intense effects 0 With high doses some users experience a sense of dissociation so severe that they feel as if they are dying 0 Use and abuse are associated with temporary memory loss impaired thinking a loss of contact with reality violent behavior and breathing and heart problems that are potentially lethal 0 Regular use may develop tolerance and cravings PCP and Ketamine alter the distribution in the brain of glutamate a fast acting excitatory neurotransmitter Excitatory neurotransmitters induce brain activity and may underlie the violent impulsive effects of these drugs Glutamate can be toxic it actually kills neurons if too much is present Thus by increasing levels of glutamate DA may eventually lead to cell death in brain areas that have receptors for this neurotransmitter which would explain the memory and other cognitive deficits observed in people who abuse drugs Genes may predispose some people to develop abuse of or dependence on these substances Psychological factors related to substance use disorders include observational learning of what to expect from taking the drugs and of using the drugs as a coping strategy Classical conditioning of stimuli related drug use can lead to cravings and can play a role in building tolerance hence overdoses are more likely when those cues are not present In addition the disorders may arise in part from operant conditioning reinforcement of the effects Social factors related to substance use disorders include the individuals relationships with family members peers use of substances cultural norms and perceived norms about appropriate and use of and 39 factors rrr These factors form feedback loops Genes influence temperament which in turn influences an individual s choice of peer group and willingness to experiment with drugs The relationship also works the other way Social factors can influence what peer groups are available to an individual which in turn influences the models he or she observes of how to cope and of the perceived norms of substance use which leads to specific neurological effects which further influence substance use TREATING SUBSTANCE USE DISORDERS Two alternative goals guide treatments for substance abuse and dependence One goals is 2 g completely stopping use and lnam39m 1 5quot il rm lessening the harmful effects related to the substance abuse or dependence Relapse rates of those quitting through abstinence are high particularly among patients with comorbid disorders Medications have been developed with helping 1 those that minimize withdrawal symptoms 2 those that block the high if the substance is used thereby leading to extinction Detoxification May involve a gradual decrease in dosage over a period of time to prevent potentially lethal withdrawal symptoms such as seizures Hyman and Obrien proposed that treatment should not end with detox but rather should be a long term venture Medications 1 interfere with the pleasant effects of drug use 2 reduces the unpleasant effects of withdrawal 3 they help maintain abstinence Stimulants have the most direct effects on the dopamine reward system Medications that modify the action of the dopamine receptors have not yet been developed for on minimize r by substituting a less harmful drug in the same category for the more harmful one Naltrexone is another medication used to treat alcohol abuse after detox Naltrexone indirectly reduces activity in the dopamine system making drinking alcohol less rewarding To prevent seizures in patients undergoing detox they may be given benzodiazepines along with beta blocker atenolol Stages of Change Precontemplation The user does not admit that there is a problem and doesn t intend to change A temporary decrease in use in response to pressure from others will be followed by a relapse when the pressure is lifted 2 Contemplation The user admits that there is a problem and may contemplate taking action However no actual behavioral change is undertaken at this stage behavior change is something considered for the future People with substance abuse and dependence may never get past this stage 3 Preparation The user is prepared to change He or she has a specific commitment to change a plan for change and the ability to adjust the plan of action and intends to start changing the substance using behavior within a month The user is very aware of the abuse how it reached its current level and available solutions Although users in this stage are prepared to change some are more ambivalent than others and may not implement the intended changes essentially reverting to the contemplation stage 4 Action The user actually changes his or her substance use behavior and environment At this stage others most clearly perceive the users intentions to stop or decrease substance use it is during this stage that family members and friends generally offer the most help and support 5 Maintenance The user builds on gains already made in stopping or decreasing substance use and tries to prevent relapses Former substance users who do no devote significant amounts of energy and attention to relapse prevention are likely to relapse all the way to the contemplation or even precontemplation stage Help and support from others are usually less forthcoming at this stage In motivational enhancement therapy the patients sets his or her own goals regarding substance use and the therapists points out discrepancies between the users stated personal goals and his or her current behavior The therapists then elictits the users desire to meet the goals overriding the rewarding effects of drug use Therapists using motivational enhancement therapy do not dispense advice or seek to increase any specific skills rather they focus on increasing the motivation to change drug use Cognitive Behavior Therapy CBT focuses on 3 general themes 1 Understanding and changing thoughts feelings and behaviors that lead to substance use antecedents Iquot Understanding and changing the consequences of the substance use 3 Developing alternative behaviors to substitute for substance use Mei ni vm gameni39l The desired behavior is reinforced with one or more of these consequences 0 Monetary vouchers the value of which increases with continued abstinence o Decreasing the frequency of mandatory counseling sessions if treatment has been court ordered 0 More convenient appointment times 0 Being allowed to take home a small supply of methadone for those being treated for heroin use Positive incentives are more effective than negative consequences Relapse often increases when rewards are discontinued Once the patient has stopped abusing the substance behavioral treatment may focus on preventing relapse by extinguishing the conditioned response to drug related cues Treatment may also focus of decreasing the frequency or intensity of emotional distress which can contribute to relapse Twelvestep facilitation TSF is based on 12 steps or principles that form the basis of AA AA views alcohol abuse as a disease that can never be cured although alcohol related behaviors can be modified by the alcoholics recognizing that he or she has lost control Although studies have not shown a neat match between specific types of patients and specific treatments two general findings have emerged 1 For patients who abuse more than one substance a single treatments program that focuses on polysubstance abuse tends to be more effective than a series of programs that focus on one at a time 2 Patients who have substance abuse or dependence and another psychiatric disorder fared better when the other disorder was also treated Social factors are targeted by residential treatment and other types of community based treatment group therapy and selfhelp groups as well as family therapy to address issues of communication power and control Anxiety disorders involve significant fear agitation and nervousness and can impair functioning in any or all spheres of life including school 6 types of anxiety disorders 1Generalized anxiety disorder 2Panic disorder 3Social phobia 4Specific phobias 50bsessive compulsive disorder 6Posttraumatic stress disorder Anxiety refers to a sense of agitation or nervousness which is often focused on an upcoming potential danger Extreme anxiety is a persistent vague sense of dread or foreboding when not in the presence of a feared stimulus Symptoms of anxiety or avoidance may occur in many psychological disorders including mood disorders somatization disorder body dysmorphic disorders and anorexia nervosa About 50 of people with an anxiety disorder are also depressed Tripartite Model of Anxiety and Depression 1 High level of negative emotions which include general distress Both anxiety and depressive disorders can involve poor concentration sleep disturbances and irritability as well as anxious apprehension This part of the model represents the common factor shared by anxiety disorders and depression 2 Low level of positive emotions Symptoms of depression include a lack of enjoyment and slowed motor functioning Low positive affect is a symptom of depression but generally not a symptom of anxiety disorders 3 Physiological hyper arousal over arousal which is found in anxiety disorders but not in depression Approx 1025 of those with anxiety disorders also abuse or are dependent on alcohol The key symptoms of anxiety disorders are extreme anxiety intense arousal and attempts to avoid stimuli that lead to fear and anxiety Generalized Anxiety Disorder characterized by uncontrollable worry and anxiety about a number of events or activities that are not solely the focus of another Axis I disorder Patients with GAD have more gray and white matter in the superior temporal gyrus an area used in hearing and language comprehension than do individuals Increasing heart rate and breathing rate increasing sweat on your palms and dilated pupils are ways your body automatically responds when you perceive a threat The fight or flight response activates the sympathetic nervous system and prepares the body for a significant expidenture of physical energy GAD can be best understood by using the neuropsychosocial approach to examine its etiology by considering neurological psychosocial and social factors The right hemisphere of the brain appears to play a special role in GAD that a complex mix of neurotransmitters is involved in the disorder and that genetics sets the stage by predisposing someone to develop GAD GAD is associated with decreased arousal that arises from an unusually responsive parasympathetic nervous system When a person with GAD perceives a threatening stimulus his or her subsequent worry temporarily reduces any arousal suppresses negative emotions and produces muscle tension Numerous studies suggest that a wide range of neurotransmitters including gamaaminobutryic acid GABA serotonin and norepinephrine may not function properly in people with GAD