Power. Point Lecture Notes Presentation Chapter 10 Substance Related Disorders Abnormal Psychology, Eleventh Edition by Ann M. Kring, Gerald C. Davison, John M. Neale, & Sheri L. Johnson
Table 10. 1 Percentage of US Population Reporting Drug Use in Past Month (2006) Copyright 2009 John Wiley & Sons, NY 2
Substance Dependence and Abuse l Substance dependence (addiction) » Occupational or social problems, much time trying to obtain substance, continued use despite problems, etc. l 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 l l Restlessness, anxiety, cramps, death Substance abuse » Maladaptive use of substance » No physiological dependence l In 2006, 22 million met criteria for dependence or abuse. » Of those 15 million involved alcohol. Copyright 2009 John Wiley & Sons, NY 3
Alcohol Dependence and Abuse l Alcohol abuse » Negative social and occupational effects » No tolerance, withdrawal, or compulsive usage l Alcohol Dependence » More severe symptoms such as tolerance and withdrawal » Withdrawal results in: – – – Anxiety Depression Weakness Restlessness Insomnia Muscle tremors l Face, fingers, eyelids, other small musculature – Elevated BP, pulse, temperature Copyright 2009 John Wiley & Sons, NY 4
Alcohol Abuse and Dependence l Delirium tremens (DTs) » Can occur when blood alcohol levels drop suddenly » Results in: – Deliriousness – Tremulousness – Hallucinations l l Primarily visual; may be tactile 2. 5% of alcohol abusers develop dependence Copyright 2009 John Wiley & Sons, NY 5
Alcohol Abuse and Dependence l Polydrug abuse » Many users abuse multiple substances – e. g. , cigarettes, cocaine, marijuana – 85% of alcohol are smokers l Synergistic » Some combinations of drugs produce stronger reaction – Alcohol and barbiturates l May cause death – Alcohol and heroin l Alcohol reduces amount of heroin needed to produce lethal dose Copyright 2009 John Wiley & Sons, NY 6
Prevalence of Alcohol Abuse l Lifetime prevalence (Kessler et al. , 1994) l Lifetime prevalence: l Binge drinking l Heavy use drinking » 5 drinks, 5 or more times in a 30 day period » 20% for men » 8% for women » Abuse - 17% » Dependence – 12% » 5 drinks in short period » 43. 5% prevalence among college students – 17. 6% prevalence among college students Copyright 2009 John Wiley & Sons, NY 7
Prevalence of Alcohol Abuse l l White adolescents and adults more likely to abuse alcohol than African Americans Binge & heavy use drinking lowest among Asian Americans Alcohol dependence highest among Native Americans and Hispanics 21. 3% of those with alcohol abuse or dependence also have at least 1 mental disorder » e. g. personality, mood, or anxiety disorders, or schizophrenia Copyright 2009 John Wiley & Sons, NY 8
Short-term Effects of Alcohol l Enters the bloodstream through small intestine » metabolized by the liver l Effects vary by concentration » Concentration varies by gender, height, weight, liver efficiency l Affects brain areas associated with error monitoring and decision making. Biphasic effect » Initially stimulates » Later depresses – Increase in negative emotions Copyright 2009 John Wiley & Sons, NY 9
Short-term Effects of Alcohol l Effect of ingesting large amounts » » » l 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 Copyright 2009 John Wiley & Sons, NY 10
Long-term Effects of Alcohol l Malnutrition l » Calories from alcohol lack nutrients » Alcohol interferes with digestion and absorption of vitamins from food l Deficiency of B-complex vitamins l l » Amnestic syndrome – Severe loss of memory for both long and short term information l l Cirrhosis of the liver » Liver cells engorged with fat and protein impeding functioning » Cells die triggering scar tissue which obstructs blood flow » Liver disease and cirrhosis rank 12 th in US causes of death. Damage to endocrine glands and pancreas Heart failure Erectile dysfunction Hypertension Stroke Capillary hemorrhages » Facial swelling and redness, especially in nose l Destruction of brain cells » Especially areas important to memory Copyright 2009 John Wiley & Sons, NY 11
Fetal Alcohol Syndrome l Heavy alcohol intake during pregnancy » Fetal growth slowed – Cranial, facial and limb anomalies occur l Moderate alcohol intake » 1 drink per day » Learning and memory impairments » Growth deficits l Total abstinence recommended by NIAAA Copyright 2009 John Wiley & Sons, NY 12
Nicotine and Cigarette Smoking l 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 Copyright 2009 John Wiley & Sons, NY 13
Prevalence and Health Consequences l l About 440, 000 Americans die prematurely each year (USD-HHS, 2004) Cigarettes kill 1, 100 people every day » 1 of 6 deaths related to tobacco use l l Lung cancer is most common cancer Cigarettes also cause or exacerbate: » Emphysema, cancers of larynx, esophagus, pancreas, bladder, cervix, stomach » Sudden infant death syndrome and pregnancy complications » Cardiovascular disease Copyright 2009 John Wiley & Sons, NY 14
Prevalence and Health Consequences l l Prevalence decreased since mid 1960 s although use increased through the 1990 s, 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 l Chinese Americans have lower lung cancer rates » Metabolize less nicotine l More prevalent among men than women » Exception: 12 to 17 year olds l Secondhand smoke (ETS, environmental tobacco smoke) » Higher levels of ammonia, carbon monoxide nicotine and tar » Causes 40, 000 deaths per year in US Copyright 2009 John Wiley & Sons, NY 15
Marijuana Drug derived from dried and ground leaves and stems of the female hemp plant (Cannibis sativa) l Hashish l » Stronger than marijuana » Produced by drying the resin exudate of the tops of plants Copyright 2009 John Wiley & Sons, NY 16
Prevalence l Most frequently used illicit drug in US » 15, 000 reported using it in 2006 l l Heavier use in US than in Europe, African, or Canada Peaked in 1979 then began to decline » Rose again in 90 s l Greater use by men than women although rates among women increased faster in 1990 s Copyright 2009 John Wiley & Sons, NY 17
Figure 10. 2 Trends in Young Adults’ Use in Previous Month from 2002 to 2006 Copyright 2009 John Wiley & Sons, NY 18
Effects of Marijuana l Major active ingredient l » THC (delta-9 tetrahydrocannabinol) l 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 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 – Impairment present for several hours after ‘high’ has worn off Copyright 2009 John Wiley & Sons, NY 19
Marijuana and the Brain l CB 1 and CB 2 » Two cannabinoid brain receptors » High concentration in hippocampus – Contributes to STM deficits l Increased blood flow to emotion regions l Decreased blood flow to temporal lobe » Amygdala and anterior cingulate gyrus » Associated with auditory attention – Poor performance on listening tasks l Habitual use leads to tolerance » Withdrawal symptoms also observed Copyright 2009 John Wiley & Sons, NY 20
Therapeutic Effects of Marijuana l l 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 Copyright 2009 John Wiley & Sons, NY 21
Opiates l Group of addictive sedatives that in moderate doses relieve pain and induce sleep » » l Opium Morphine Heroin Codeine Synthetic sedatives » Seconal and valium l Opiates legally prescribed as pain medications include: » Hydrocodone combined with other substances yields Vicodin, Zydone, and Lortab » Oxycodone the basis for Oxy. Contin, Percodan, & Tylox. Copyright 2009 John Wiley & Sons, NY 22
Prevalence of Opiate Use l Herion » Estimated 1, 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. l Heroin is more pure (25 to 50%) than in the past » Increases likelihood of overdose l Oxy. Contin 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 Copyright 2009 John Wiley & Sons, NY 23
Psychological and Physical Effects of Opiates l Euphoria, drowsiness, reverie, and lack of coordination » Loss of inhibition, increased self-confidence » Severe letdown after about 4 to 6 hours l Heroin and Oxy. Contin » Rush – Intense feelings of warmth and ecstasy following injection l Stimulate receptors of the body’s opioid system » Endorphins and enkephalins l 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 Copyright 2009 John Wiley & Sons, NY 24
Psychological and Physical Effects of Opiates l 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 l Many users resort to illegal activities to obtain money for drugs » Theft, prostitution, dealing drugs l Exposure to infectious diseases via shared needles » e. g. HIV » Evidence suggests that free needles reduces infectious diseases associated with IV drug use Copyright 2009 John Wiley & Sons, NY 25
Figure 10. 3 ER Visits for Hydrocodone and Oxycodone ODs Copyright 2009 John Wiley & Sons, NY 26
Synthetic Sedatives l Barbituates l » Induce muscle relaxation, reduce anxiety, produce mild euphoria » In 1940 s prescribed to aid sleep » Usage declined from 1975 thru 1990 s but increased recently l Other synthetic sedatives » Benzodiazepines – e. g. , Valium, Ketamine l Stimulate GABA system Heavy dosages » Slurred speech » Unsteady gait » Impaired judgment & concentration » Irritability & combativeness » Accidental suffocation due to excessive relaxation of diaphragm muscles l l Alcohol magnifies depressant effects Tolerance & withdrawal » Delirium, convulsions & other symptoms Copyright 2009 John Wiley & Sons, NY 27
Stimulants: Amphetamines l l l 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) Copyright 2009 John Wiley & Sons, NY 28
Stimulants: Methamphetamine l Amphetamine derivative (aka crystal meth) » Can be taken orally, intravenously, or intranasally (snorting) » In 2006, over 700, 000 people used methamphetamine (SAMHSA, 2007). l Chronic use damages brain » Reduction in hippocampus volume (see figure 10. 4; abusers represented by yellow bars) Copyright 2009 John Wiley & Sons, NY 29
Stimulants: Cocaine l Alkaloid obtained from coca leaves » » l l 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 l Not all users develop tolerance » Some become more sensitive – May increase risk of OD l In 2006, 2. 4 million people over the age of 12 reported using cocaine, and 700, 000 reported using crack (SAMHSA, 2007). Copyright 2009 John Wiley & Sons, NY 30
Stimulants: Cocaine l Crack » Form of cocaine that quickly become popular in the 80 s » Rock crystal that is heated, melted, & smoked » Cheaper than cocaine Copyright 2009 John Wiley & Sons, NY 31
Hallucinogens, Ecstasy, and PCP l Hallucinogen effects include: » Colorful visual hallucinations » Synestesias – Overflow from one sensory modality to another l » Alterations in time perception » Lability of mood » Anxiety & paranoia LSD l Other hallucinogens Psilocybin l Mescaline l Ecstasy l PCP (phencyclidine) » d-lysergic acid diethylamide l In 2006, there were about 100, 000 users, down from 1 million in 2002 » African Americans less likely to use than others » Extracted from mushroom psilocybe mexicana » Active ingredient of peyote » Increase feelings of intimacy and enhances mood » Chemically similar to mescaline and amphetamines » Acts on serotonin » Its use peaked in 2001, with 1. 8 million users. » Angel dust » Animal tranquilizer » Causes severe paranoia and violence Copyright 2009 John Wiley & Sons, NY 32
Figure 10. 5 Process of Becoming a Drug Abuser Copyright 2009 John Wiley & Sons, NY 33
Etiology of Substance-Related Disorders: Developmental approach l Li et al. (2001) Two paths to alcohol abuse 1. First group began drinking in early adolescence, increased drinking throughout high school 2. Second group drank lesser amounts in early adolescence, increased drinking in middle school and again in high school. – l 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 Copyright 2009 John Wiley & Sons, NY 34
Etiology of Substance-Related Disorders: Genetic Factors l l Relatives and children of problem drinkers have higher-thanexpected 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 l l 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 – Evidence for physiological intolerance in this group l CYP 2 A 6 » Gene associated with metabolism of nicotine » Smokers with defect in this gene less likely to become dependent (Rao et al. , 2000) Copyright 2009 John Wiley & Sons, NY 35
Etiology of Substance-Related Disorders: Neurobiological Factors l l 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 DRD 2 l People take drugs to avoid the bad feelings associated withdrawal » Explains frequency of relapse l 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 l 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. Copyright 2009 John Wiley & Sons, NY 36
Figure 10. 6 Reward Pathways in Brain affected by Different Drugs Copyright 2009 John Wiley & Sons, NY 37
Etiology of Substance-Related Disorders: Psychological factors l 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 l » 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. » Crying in one’s beer l 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 Copyright 2009 John Wiley & Sons, NY 38
Etiology of Substance-Related Disorders: Psychopathology and Personality l 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 l Kindergarten children who were rated high in anxiety and novelty seeking more likely to get drunk, smoke, and use drugs in adolescence. Copyright 2009 John Wiley & Sons, NY 39
Etiology of Substance-Related Disorders: Sociocultural factors l Alcohol is the most common abused substance worldwide (Smart & Ogborne, 2000) » Highest consumption in France, Spain, & Italy where consumption is widely accepted (de. Lint et al. , 1978) l Men consume more alcohol than women but differences vary by country » Israel – Men drank 3 x as much as women » Netherlands – Men drank 1½x as much as women l Availability » Usage is higher when alcohol and drugs are easily available – In 2003, drug use among youths who had been approached by drug dealers was 35 percent, compared to just under 7 percent among youths who had not been approached Copyright 2009 John Wiley & Sons, NY 40
Etiology of Substance-Related Disorders: Sociocultural factors l 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. , 1995 a) » Lack of parental monitoring linked to higher drug usage (Chassin et al. , 1996; Thomas et al. , 2000) Copyright 2009 John Wiley & Sons, NY 41
Etiology of Substance-Related Disorders: Sociocultural factors l 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) l Advertising and Media » Countries that ban ads have 16% less consumption than those that don’t (Saffer, 1991) Copyright 2009 John Wiley & Sons, NY 42
Treatment of Substance Related Disorders: Alcohol Abuse and Dependence l In 2006, 4 million people over the age of 12 received treatment for alcohol abuse or dependence » Over 21 million people over the age of 12 were in need of treatment for alcohol or drug problems l Inpatient hospital treatment » Detoxification – Withdrawal from alcohol under medical supervision – The therapeutic results of hospital treatment are not superior to those of outpatient treatment l 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. Copyright 2009 John Wiley & Sons, NY 43
Table 10. 2 The 12 Steps of AA Copyright 2009 John Wiley & Sons, NY 44
Treatment of Substance Related Disorders: Alcohol Abuse and Dependence l Couples and Family Therapy » Emphasizes support from problem drinker’s partner » Reduced problem drinking maintained 1 year after therapy ended » Also reduced couples’ overall level of distress Copyright 2009 John Wiley & Sons, NY 45
Treatment of Substance Related Disorders: Alcohol Abuse and Dependence l Cognitive and Behavioral Treatments » Contingency-Management Therapy – Patient and family reinforce behaviors inconsistent with drinking l e. g. , avoiding places associated with drinking – Teach problem drinker how to deal with uncomfortable situations l 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 Copyright 2009 John Wiley & Sons, NY 46
Treatment of Substance Related Disorders: Alcohol Abuse and Dependence l Controlled drinking » Belief that problem drinkers can consume alcohol in moderation » Avoid total abstinence and inebriation » Guided self-change l Medications » Antabuse (disulfiram) – Produces nausea and vomiting if alcohol is consumed » Other medications include naltrexone, naloxone, & acamprosate – Most effective when combined with CBT Copyright 2009 John Wiley & Sons, NY 47
Treatment of Substance Related Disorders: Nicotine Dependence l Peer behavior important » If others in social network stop smoking, increases likelihood that individual will also stop l Rapid smoking treatment » Rapid puffing, focused smoking, & smoke holding l Scheduled smoking » Reduce nicotine intake gradually over a few weeks l Physician’s advice » By age 65, most smokers have quit (USDHHS, 1998 b) l Nicotine replacement treatments » Gum, patches, or inhalers » Reduce craving for nicotine » Combining patch with antidepressants improved success rate Copyright 2009 John Wiley & Sons, NY 48
Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence l l 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 Copyright 2009 John Wiley & Sons, NY 49
Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence l l l 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) Copyright 2009 John Wiley & Sons, NY 50
Prevention of Substance-Related Disorders l l 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 Copyright 2009 John Wiley & Sons, NY 51
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