Abnormal Psych Psyc 3330 - 01
University of Louisiana at Lafayette
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This 17 page Class Notes was uploaded by Lauren Notetaker on Friday April 1, 2016. The Class Notes belongs to Psyc 3330 - 01 at Tulane University taught by Constance Patterson in Winter 2016. Since its upload, it has received 19 views. For similar materials see Abnormal Psychology in Psychlogy at Tulane University.
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Date Created: 04/01/16
• Substance Related Disorder What do they have in common? Perspectives on Substance-Related Disorders • Substance-Related Disorders ◦ Costs 100s of billions of dollars ◦ Kills estimated 500,000/year in the U.S. ◦ Implicated in street crime, gang violence, and homelessness ◦ Wide-ranging effects: • Psychophysiological: health risks • Behavioral: think, feel, behave differently ◦ Signiﬁcant impairment and life impact ◦ Polysubstance use ◦ See National Clearinghouse for Alcohol and Drug Information http:// www.health.org/ • • Levels of Involvement with substances: ◦ Substance use = ingestion of psychoactive substances in moderate amounts that does NOT interfere with social, educational or occupational functioning ◦ Substance intoxication = physiological reaction to use of substances (alters judgment mood, and motor ability); is reversible as substance ‘wears off’ ◦ Substance abuse = deﬁned in terms of how signiﬁcantly it interferes with functioning ◦ Substance dependence = requires greater amounts to obtain same effect / withdrawal would result in a negative physical impact • • Substance can refer to a drug, prescription medication, or toxin (e.g., poisons, heavy metals) • Dependence and “addiction” ◦ Tolerance = requires greater amounts of the substance to obtain the same effect ◦ Withdrawal = would result in a negative physical impact when substance no longer used ◦ “Drug seeking behaviors” – efforts to obtain and use a substance • • Remission speciﬁers include: ◦ Early Full Remission = at least 1 mo. but less than 12 mo. No criteria for Dependence or Abuse is met ◦ Early Partial Remission = at least 1 mo. but less than 12 mo. One or more criteria for Dependence or Abuse is met ◦ Sustained Full Remission = Used if none of the criteria for Dependence or Abuse is met during a 12 mo. or longer period ◦ Sustained Partial Remission = Used if one or more of the criteria for Dependence or Abuse is met during a 12 mo. or longer period • Agonist Therapy – agonist medication is used in treatment (e.g., methodone) • In a Controlled Environment – generally refers to treatment in an environment that precludes use of substances (e.g., locked hospital ward, drug free treatment community, substance free jails) • Main Categories of Substances • Depressants = decrease CNS activity (dampen arousal/behavioral sedation); alcohol, sedatives, hypnotic drugs such as barbituates and benzodiazapines • Stimulants = raise activity, alertness, mood; amphetamines, cocaine, nicotine, caffeine (increase alertness, elevate mood) • Opiates = analgesics (pain reduction), euphoria; heroin, opium, codeine, morphine • Hallucinogens = alter sensory perceptions (can produced paranoia, delusions, and hallucinations); Cannabis, LSD • Other drugs of abuse = Inhalants, Anabolic steroids, Medications •* Gambling disorder - unable to resist the urge to gamble • Categories of addictiveness Alcohol Related Disorders • Clinical Description ◦ CNS depressant but initial impact is perceived by user as stimulation • Inhibition initially reduced • Global impact with additional ingestion ◦ Neurotransmitter systems affected: • GABA – impact slows brain activity • Glutamate – impact affects memory formation • Serotonin – impact on mood, sleep and eating behaviors and craving of alcohol • Alcohol Use Disorder • Effects of Chronic Alcohol Use ◦ Intoxication ◦ Withdrawal – nausea, vomiting, hand tremors, anxiety, agitation, insomnia • Delirium tremens – tremors and hallucinations • Dementia – genetic predisposition but heavy use impairs brain function • Wernicke’s disease – confusion, loss of muscle coordination and unintelligible speech • • Fetal alcohol syndrome (FAS) – mom uses alcohol during pregnancy ◦ Growth retardation ◦ Cognitive deﬁcits ◦ Behavior problems ◦ Facial abnormalities • Role of alcohol dehydrogenase (ADH) breaks down alcohol – three forms of the enzyme but some groups (genetically) have higher levels of beta-3 ADH which is associated with FAS • US Statistics: Use and Abuse • Use in the United States: ◦ Majority of adults are light drinkers or abstainers ◦ Some level of current use = just below ~50% ◦ Binge drinking = 23% ◦ Dependence = 15 million ◦ Males > Females (but females more easily addicted) ◦ In one Study of College Students: • GPA in A range = 3 drinks a week (average) • GPA in D/F range = 11 drinks a week • Progression of Alcohol Related Disorders • Fluctuations in involvement with alcohol • Spontaneous remission • Jellinek’s Four Stage Model (Limited support) ◦ Pre-alcoholic stage – drink occasionally ◦ Prodromal – heavy drinking, no problems ◦ Crucial stage – loss of control, binges ◦ Chronic – daily procurement and using • Course of dependence = progressive • Course of abuse = variable • Alcohol and Violence • Links with aggression • Overlap NOT causality – alcohol doesn’t cause violence but lowers inhibitions for those who are already likely to be come violent • Multiple factors: ◦ Quantity of alcohol ◦ Timing of violence ◦ History of violence (past predicts future behavior) ◦ Expectations about drinking ◦ Consequences that occur while drinking • Sedative, Hypnotic, or Anxiolytic Disorder • Barbiturates – sedatives developed to help people sleep (‘hypnotic’; Amytal, Seconal, Nembutal) • Benzodiazepines – anxiety reduction drugs (Valium, Xanax, Halcion, Rohypnol) • Effects = similar to alcohol – at low doses relax muscles, produce mild feeling of well being ◦ GABA - impact slows brain activity ◦ Synergistic in combination: Dangerous • • Maladaptive behavior changes • Inappropriate sexual behaviors • Aggressive • Variable moods • Impaired judgment • Impaired function • Physiological effects • Impaired Speech • Disrupted Coordination • Odd Gait, Difﬁculty walking • Stimulant related disorder • Nature of Stimulants • Most widely consumed drug (U.S.) • Increase alertness and energy • Examples: ◦ Nicotine ◦ Caffeine ◦ Amphetamines ◦ Cocaine • Amphetamine use disorder • Effects of Amphetamines • Experience an “up” or high feeling ◦ Sense of elation ◦ Enhanced sense of vigor ◦ Reduced fatigue • Later experience “crash” as drug wears off • Extreme fatigue • Depression • • Typical impact: ◦ Behavioral symptoms – euphoria, affective blunting ◦ Changes in sociability ◦ Interpersonal sensitivity ◦ Anxiety, tension, anger ◦ Stereotyped behaviors ◦ Impaired judgment ◦ Impaired function ◦ Physiological symptoms – heart rate, blood pressure changes, perspiration/chills, nausea, vomiting, weight loss, respiratory depression, chest pains, seizures, coma ◦ Severe intoxication or overdose can cause hallucinations, panic, agitation, and paranoid delusions. ◦ Symptoms of withdrawal are similar to depression • • Designer drugs • MDMA (Ecstasy); Molly ◦ Effects similar to speed ◦ False sense of intimacy, diminished anxiety, euphoria ◦ In overdose: disorientation, agitation, paranoia, hallucinations ◦ Minimal “comedown” • Evidence: destroys serotonergic ﬁbers, decreases blood ﬂow to the brain – lasts signiﬁcant periods, even years • Methamphetamine • Puriﬁed, crystallized form of speed • Longer half-life • Dangerous potential for dependence • • CNS Effects of Amphetamines • Signiﬁcant effects ◦ Norepinephrine ◦ Dopamine • Too much neurotransmitter in the system can result in hallucinations and delusions • Cocaine Use Disorder • Effects of Cocaine • Blocks dopamine reuptake ◦ Euphoria ◦ Feelings of power and conﬁdence (short term) • Increased blood pressure/pulse – can be dangerous • Insomnia • Decreases appetite • Induces and enhances paranoia - common • • Statistics • Second most frequently abused drug ◦ 1.9 million (only marijuana use is higher) • ER admissions for cocaine • 29% Caucasian males • 23% African American males • 18% Caucasian females • 12% African American females • 17% of cocaine users also used crack • • Dependence • Highly addictive substance – people ﬁnd they have an increased difﬁculty to resist taking more • Develops slowly ◦ Tolerance develops relatively quickly – leads to need for more ◦ Often become socially isolated with greater use ◦ Atypical withdrawal ◦ Cyclical pattern • • pleasure pathways are desensitized • Nicotine Use Disorder • Effects of Nicotine • Stimulates nicotinic acetylcholine receptors within 7 to 19 seconds of inhaling • Sensations of relaxation, wellness, pleasure but also implicated in feelings of depression, anxiety, heightened sense of anger • Highly addictive – about 21% of U.S. population • Relapse rates = similar to alcohol and heroin • “Dosing” – smokers regulate their intake • Maintain a steady level of nicotine in the bloodstream • Examples: ◦ Having a cigarette before sleep ◦ Having a cigarette immediately after waking • 30-46 SLIDES Psychological Dimensions • Positive Reinforcement • Repeated pairings with rewards • • Negative Reinforcement • Escape from unpleasantness • Self-medication • Tension reduction • Coping mechanism for negative affect • Opponent-Process Theory – integrates positive and negative reinforcement • Increase in positive is followed by • Increase in negative, then followed by • Increase in positive is followed by … • • Remedy is to use more of same drug • Relationship is strengthened by use and weakened when use is stopped. • Cognitive Factors • Expectancy Effects • Beliefs about drugs and their effects (generally beliefs are about positive impact or beneﬁts) • • Cravings* • Cues • Environmental triggers • • * In treatment, failure to treat cues and triggers will result in failed treatment and relapse • Social Dimensions • Exposure to Drugs • Prerequisite for use ◦ family • Media • Peers ◦ Not strongest impact • Family – role of modeling? ◦ Monitoring ◦ Peer groups • • Societal Views • Moral weakness • Disease model ◦ AA thinks as a disease • Cultural Dimensions • Contextual normative framework • Expectations about use in speciﬁc culture ◦ Spirituality/religious traditions; family expectations and support; acceptability of speciﬁc substances; Expectations during speciﬁc celebrations; Impact of laws. • Gene-environment interactions • Values of speciﬁc culture ◦ American ppl are more likely to have use • General progressiv epattern: • Positive expectations lead to experimentation • Exp. Conﬁrms expectation san dleads to regular use • Potential with regular use is gradually using more so result is heavy uuse • Heavy use leads to dependence • All parts of this model are dependent on psychological, physiological, cultural, and social inﬂuences • NOT ON PP • In the news: • Nearly half deaths due to Opiod overdose 28,000 deaths in 2014 were due to prescription meds • More ppl die of narcotic overdose than car accidents • About 8 million americans over age of 12 need treatment for illicit drug use • 4 out of 5 addicts (80%) can't get treatment; not enough docs who know how to treat it • NOT ON PP • An Integrative Model Picture Treatment - Biological • Agonist Substitution • Safer drug • Similar chemical composition ◦ Ex: methadone and nicotine gum or patch • • Antagonistic Treatment • Block or counteract pleasurable effects ◦ Ex: naltrexone for opiate and alcohol • • Aversive Treatment • Make use of drugs extremely unpleasant ◦ Ex: Antabuse for alcoholism • Medications • Cope with withdrawal symptoms • Efﬁcacy • Limited when used alone • Better with psychosocial therapy • Medical treatment of related problems: malnutrition, dementia, other physical problems • Chart! Treatment - psychosocial • Inpatient Facilities • Expensive • Efﬁcacy has been shown as equal to outpatient (now, generally for most severe cases) • • Alcoholics Anonymous (12 step) • Most popular • Social support • Limited research • Effective for highly motivated • Chart • Controlled Use Treatment Approaches • Expensive? • Teach them cautions, psychological pieces; short term is helpful • Teach controlled drinking habits • Moderation • Possible beneﬁts • Fairly new approach • Used with substance abusers from upper socio-economic class to date • Limited research to support this approach • • Component Treatment • Comprehensive • Individual and group therapy - effective ◦ They would do mental health treatment ﬁrst but now there's dual treatment • Aversion therapy • Covert sensitization • Contingency management (learn to manage cues and environmental stimuli) • • Community reinforcement • Involvement of collateral (signiﬁcant other) • Behavioral analysis ◦ Antecedents and consequences • Social service assistance • New recreational activities • • Relapse prevention • Learned aspects of dependence • Address distorted cognitions • Identify negative consequences • Increase motivation to change • Identify high risk situations • Reframe relapse ◦ failure of coping skills, not person • • Prevention approaches • Education-based (DARE) ◦ Research shows limited efﬁcacy • • Comprehensive (skills training) ◦ Promising preliminary results • • Cultural change ◦ Media promotion Chapter 11 Substance related and Impulse control Disorder Addiction: Gambling Disorder • Pattern of urges common to substance related disorders ◦ Persistent and recurrent problematic gambling behavior, including signiﬁcant distress and/or impairment ◦ In a 12 month period ◦ Needs to gamble with increasing amounts of money in order to achieve the desired excitement ◦ Repeated unsuccessful attempts to cut down, control, stop gambling ◦ Preoccupied with gambling, reliving, planning ◦ Gambles when feeling distressed, to feel better ◦ After losing, goes back to break even ◦ Lies to conceal gambling, negative impact on relationships, jobs, education, career, ◦ Relies on others to bail out or relieve situation caused by gambling • “Games of chance” – On what will people place bets? ◦ Casinos: slot machines, card games, and roulette. ◦ Games now available on the Internet: the bettor can use a credit card instead of cash or chips. ◦ State lottery ◦ Horse or dog racing ◦ Bingo. ◦ Bets on the outcome of an election, baseball or football games, or even the weather on a particular day. • May develop slowly over time or may occur after decades of social gambling at a point when high stress life situation occurs • Will continue to gamble even after they have developed social, economic, interpersonal, or legal problems as a result of the gambling: • May commit crimes (stealing, embezzling, or forging checks) to get money for their "habit.“ • Marital and family relationships may also be lost as a result of the disorder • Jobs may be lost or at risk because of gambling Addiction: Pathological Gambling • 3-5% of adult Americans (growing rate) • Biological inﬂuences • Poor impulse regulation • Dopamine, Serotonin • Psychological inﬂuences • Denial, impulsivity, “unrealistic optimism” • Treatment • Similar to substance dependence • http://www.ncpgambling.org/ • resource about issues related to problem gambling • and its treatment Prevention: National Council on Problem Gambling • The Holiday Lottery campaign encourages parents and loved ones not to give lottery products as holiday gifts to minors. Research shows that the majority of adolescents gamble at least occasionally, and that lottery products may be a gateway to problem gambling. Youth gambling has been shown to be linked to other risk-taking and addictive behaviors such as smoking, drinking and drug use • The REAP mission is to educate athletes of all ages about the personal and professional risks involved with gambling and other risky behavior and to encourage good decision making. REAP was designed for a specific audience by a group of individuals with knowledge about gambling, sports, and sports wagering. General Pattern for Impulse Control Disorders • Begins with an urge that is difﬁcult to resist or “irresistible” • Generally the urge is self-defeating or self-destructive in nature • Tension builds around the urge to act • Sometimes there is pleasurable anticipation Impulse-control Disorders: Intermittent Explosive Disorder • Deﬁnition: ◦ Intermittent explosive disorder: repeated episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which the person reacts in a manner that is grossly out of proportion to the situation. Road rage, domestic abuse, throwing or breaking objects, or other temper tantrums may be signs of intermittent explosive disorder. • May attack others and their possessions, causing bodily injury and property damage; may injure themselves during an outburst. • Later, may feel remorse, regret or embarrassment. • Episodes last less than 30 minutes, verbal assaults, injuries, deliberate destruction of property; may occur in clusters or separated by weeks or months of nonaggression. Between outbursts, may be irritable, impulsive, aggressive or angry. • May be preceded or accompanied by: ◦ Irritability, Increased energy, Rage, Racing thoughts, Tingling, Tremors, Palpitations, Chest tightness, or Feeling of pressure in the head • Depression, fatigue or relief may occur after the episode. • Environment. grow up in families where explosive behavior, verbal and physical abuse are common. Exposure to this type of violence at an early age increases potential person will exhibit the same behaviors as they mature. • Genetics. There may be a genetic component • Brain chemistry. Potential differences in serotonin, • People with other mental illnesses (mood, anxiety or personality disorders) or certain medical conditions (Parkinson's disease or traumatic brain injury) may display aggressive behaviors, but not be diagnosed because the cause is from another condition. • A number of factors increase risk of developing intermittent explosive disorder: ◦ History of substance abuse. Lowers inhibitions and compromises control of socially inappropriate behaviors ◦ History of physical abuse. Modeling by key ﬁgures ◦ Age. Onset in the teens and 20s. ◦ Being male. More likely to have intermittent explosive disorder. • People with intermittent explosive disorder have an increased risk of: ◦ Self-harm - signiﬁcantly increased risk of harming themselves, either with intentional injuries or suicide attempts. Those who use substances or have comorbid mental disorders are at greatest risk ◦ Impaired interpersonal relationships- often perceived by others as always being angry ◦ Trouble at work, home or school - may include school suspension/expulsion, job loss, auto accidents, ﬁnancial problems or trouble with the law. • Cognitive behavioral therapy - identify the situations or behaviors that trigger an aggressive response; teach people how to manage anger and control inappropriate responses using techniques such as relaxation training, thinking differently about situations (cognitive restructuring) and learning coping skills. • Medication - Different types of drugs depending on the full symptom picture (attending to comorbid conditions: ◦ Antidepressants ◦ Anticonvulsants ◦ Anti-anxiety agents ◦ Mood stabilizers Impulse-control Disorders: Kleptomania • Kleptomania is a complex disorder characterized by repeated, failed attempts to stop stealing • People with this disorder have an overwhelming urge to steal and get a thrill from doing so. • The recurrent act of stealing may be restricted to speciﬁc objects and settings, but the person may or may not be able to describe these special preferences. • There may be preferred objects/environments where theft occurs. • People with this disorder usually exhibit guilt after the theft. • Detection of kleptomania, even by signiﬁcant others, is difﬁcult so the disorder often proceeds undetected. One theory proposes that the thrill of stealing helps to alleviate symptoms in persons who are clinically depressed. • High comorbidities with: ◦ Mood disorders ◦ Substance abuse & dependence ◦ Major depression ◦ Panic attacks, social phobia, ◦ Eating disorders ◦ Obsessive Compulsive Disorder • Many with kleptomania live with “secret shame” • Afraid to seek mental health treatment. • There is no cure for kleptomania, however, medication and/or psychotherapy may help end the cycle of compulsive stealing. • An estimated 5 percent of shoplifters have kleptomania. • Often begins during adolescence or in young adulthood; rarely, there is onset after age 50 • Risk factors may include: ◦ Family history. Having a ﬁrst-degree blood relative (parent or sibling) with kleptomania or obsessive-compulsive disorder ◦ Being female. Approximately two-thirds of people with known kleptomania are women. • Once the disorder is suspected and veriﬁed by an extensive psychological interview, therapy is normally directed towards impulse control, as well as any accompanying mental disorder(s). • Relapse prevention strategy training, with a clear understanding of speciﬁc triggers, must be stressed. • Cognitive Behavioral Treatment has best support • Prozac has limited utility in some cases (usefulness depends on full symptom picture and comorbid conditions) Impulse-control disorders: Pyromania • Irresistible urge to set ﬁres • Tension leading up to setting ﬁre, and release of tension or relief afterward • < 4% of arsonists • Role of personality disorders? • Role of substance abuse • Little etiological and treatment research ◦ CBT • Those who set deliberate ﬁres appear to suffer from a breakdown between conventional social mores and personal rules of conduct and appear to lack a control system that provides the checks and balances against dangerous and socially unacceptable behavior (Medscape, 2013) • Subtypes: development and Course of Pyromania ◦ 1. Curiosity = nonmalevalent activity “gone wrong – essentially trying it out • Usually onset before age 7 ◦ 2. Thought Disordered = misperception of reality around religion, political, personal agenda; focus institutions: churches, schools, ◦ 3. Delinquent = typical group focused, may involve drugs, alcohol; high risk of adult continuation of pattern ◦ 4. Thrill seeker* = early to mid-adolescent onset; “danger for its own sake”; arsonists, ﬁreﬁghters – high risk of reoffending ◦ 5. Revenge based = Late childhood to adolescent onset; experiment with incendiaries and explosives; usually raised in families that value “getting even”; speciﬁc targets; may use ﬁre bombs; little emotional expression aside from anger, suspicion, resentment ◦ 6. Compulsive* = least common; late adolescent to adult onset; will set ﬁres as an angry response to event of loss usually within a four week “window” around anniversary personally meaningful event ◦ 7. Disordered coping* = onset under age 6; random and opportunistic; high risk of numerous ﬁres (100s) seems to be method of coping; few friends from early childhood, loners; poor capacity for empathy, doesn’t understand impact of ﬁres on others ◦ * Indicates potential of developing into impulse control disorder • Other Areas Under Study as Potential Impulse Control Disorders • Sexual compulsion (sexual addiction?) • Internet addiction – addiction to other devices • “iphone is like crack” • Compulsive shopping (“QVC addiction”?) • Non-suicidal Self Injury – impulse control issues are not clear; but usually self injure to “feel something” or escape, not in response to building tension
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