Substance-Related Disorders

Perspectives on Substance-Related Disorders

• The Nature of Substance-Related Disorders– Problems related to the use and abuse of psychoactive substances– Produce wide-ranging physiological, psychological, and behavioral

effects • Some Important Terms and Distinctions

– Substance use vs. substance intoxication– Substance abuse vs. substance dependence– Tolerance vs. withdrawal

Perspectives on Substance-Related Disorders (cont.)

• Five Main Categories of Substances– Depressants – Result in behavioral sedation (e.g., alcohol,

sedative, anxiolytic drugs)– Stimulants – Increase alertness and elevate mood (e.g., cocaine,

nicotine, caffeine) – Opiates – Primarily produce analgesia and euphoria (e.g., heroin,

morphine, codeine)– Hallucinogens – Alter sensory perception (e.g., marijuana, LSD)– Other drugs of abuse – Include inhalants, anabolic steroids,

medications

Figure 10.1

• **Ice, LSD, chocolate, TV: Is everything addictive?

Figure 10.2

Easy to get hooked on, hard to get off

The Depressants: Alcohol Use Disorders

• Psychological and Physiological Effects of Alcohol

– Central Nervous system depressant

– Influences several neurotransmitter systems, but mainly GABA

• Effects of Chronic Alcohol Use

– Alcohol intoxication

– Alcohol withdrawal

– Associated brain conditions – Demenita and Wernicke’s disease

– Fetal alcohol syndrome

• DSM-IV Criteria for Disordered Alcohol Use

Figure 10.3

The path traveled by alcohol throughout the body

Alcohol: Some Facts and Statistics

• In the United States

– Most adults consider themselves light drinkers or abstainers

– Most alcohol is consumed by 11% of the U.S. population

– Alcohol use is highest among Caucasian Americans

– Males use and abuse alcohol more so than females

– Violence is associated with alcohol, but alcohol alone does not cause aggression

• Statistics on Abuse and Dependence

– 10% of Americans experience problems with alcohol

– Most persons with alcoholism can moderate or cease drinking

– 20% of those with alcohol problems experience spontaneous recovery

Sedative, Hypnotic, or Anxiolytic Substance use Disorders: An Overview

• The Nature of Drugs in This Class

– Sedatives – Calming

– Hypnotic – Sleep inducing (e.g., barbiturates)

– Anxiolytic – Anxiety reducing (e.g., benzodiazepines)

• Effects of Such Drugs Are Similar to Large Doses of Alcohol

– Combining such drugs with alcohol is synergistic

• All Exert Their Influence Via the GABA Neurotransmitter System

• DSM-IV Criteria for Sedative, Hypnotic, or Anxiolytic Substance Use Disorders

Stimulants: An Overview

• Nature of Stimulants

– Most widely consumed drug in the United States

– Such drugs increase alertness and increase energy

– Examples include amphetamines, cocaine, nicotine, and caffeine

Stimulants: Amphetamine Use Disorders

• Effects of Amphetamines

– Produce elation, vigor, reduce fatigue

– Such effects are followed by a “crash” (e.g., feeling depressed and tired)

– Enhance the release of dopamine and norepinephrine, while blocking reuptake

• DSM-IV Criteria for Amphetamine Intoxication

– Psychological symptoms

– Physiological symptoms

• Ecstasy and Ice

– Produces effects similar to speed, but without the crash

– 2% of college students report using Ecstasy

– Both drugs can result in dependence

Stimulants: Cocaine Use Disorders

• DSM-IV Criteria for Cocaine Intoxication and Withdrawal

– Psychological symptoms

– Physiological symptoms

– Most cocaine users cycle through patterns of tolerance and withdrawal

• Effects of Cocaine

– Produce short lived sensations of elation, vigor, reduce fatigue

– Cocaine use in the United States has declined over the last decade

– Effects result from blocking the reuptake of dopamine

– Cocaine is highly addictive, but addiction develops slowly

Stimulants: Nicotine Use Disorders

• Effects of Nicotine

– Stimulates the central nervous system, specifically nicotinic acetylcholine receptors

– Results in sensations of relaxation, wellness, pleasure

– Nicotine is highly addictive

• DSM-IV Criteria for Nicotine Withdrawal Only

– Psychological symptoms

– Physiological symptoms

– Nicotine users dose themselves to maintain a steady state of nicotine

Figure 10.6

Relapse rates for nicotine compared to alcohol and heroin

Stimulants: Caffeine Use Disorders

• Effects of Caffeine – The “Gentle” Stimulant

– Used by over 90% of Americans

– Found in tea, coffee, cola drinks, and cocoa products

– Small doses elevate mood and reduce fatigue

– Regular use can result in tolerance and dependence

– Caffeine blocks the reuptake of the neurotransmitter adenosine

• DSM-IV Criteria for Caffeine Intoxication

– Psychological symptoms

– Physiological symptoms

Opiods: An Overview

• The Nature of Opiates and Opiods– Opiate – Natural chemical in the opium poppy with narcotic effects (i.e., pain

relief)– Opiods – Refers to a class of natural and synthetic substances with narcotic

effects– Such drugs are often referred to as analgesics – Examples include heroin, opium, codeine, and morphine

• Effects of Opiods– Low doses induce euphoria, drowsiness, and slowed breathing– High doses can result in death– Withdrawal symptoms can be lasting and severe– Activate body’s enkephalins and endorphins

• DSM-IV Criteria for Opiod Intoxication and Withdrawal– Psychological symptoms– Physiological symptoms– Mortality rates are high for opiod addicts

Hallucinogens: An Overview

• Nature of Hallucinogens– Substances that change the way the user perceives the world– May produce delusions, paranoia, hallucinations, and altered

sensory perception– Examples include marijuana, LSD

• Marijuana– Active chemical is tetrahydrocannabinol (THC)– May produce several systems (e.g., mood swings, paranoia,

hallucinations)– Impairment in motivation is not uncommon (i.e., amotivational

syndrome)– Major signs of withdrawal and dependence do not typically occur

Hallucinogens: An Overview (cont.)

• LSD and Other Hallucinogens– LSD is most common form of hallucinogenic drug– Tolerance tends to be rapid, and withdrawal symptoms are

uncommon– Psychotic delusional and hallucinatory symptoms can be

problematic• DSM-IV Criteria for Marijuana and Hallucinogen Intoxication

– Psychological and physiological symptoms are similar

Other Drugs of Abuse: Inhalants

• Nature of Inhalants

– Substances found in volatile solvents that are breathed into the lungs directly

– Examples include spray paint, hair spray, paint thinner, gasoline, nitrous oxide

– Such drugs are rapidly absorbed with effects similar to alcohol intoxication

– Tolerance and prolonged symptoms of withdrawal are common

– DSM-IV criteria for inhalant intoxication

Other Drugs of Abuse: Anabolic Steroids

• Nature of Anabolic-Androgenic Steroids

– Steroids are derived or synthesized from testosterone

– Used medicinally or to increase body mass

– Users may engage in cycling or stacking

– Steroids do not produce a high

– Steroids can result in long-term mood disturbances and physical problems

Other Drugs of Abuse: Designer Drugs

• Designer Drugs

– Drugs produced by pharmaceutical companies for diseases

– Ecstasy, MDEA (“eve”), BDMPEA (“nexus”), ketamine (“special K”) are examples

– Such drugs heighten auditory and visual perception, sense of taste/touch

– Becoming popular in nightclubs, raves, or large social gatherings

– All designer drugs can produce tolerance and dependence

Causes of Substance-Related Disorders: Family and Genetic Influences

• Results of Family, Twin, and Adoption Studies

– Substance abuse has a genetic component

– Much of the focus has been on alcoholism

– Genetic differences in alcohol metabolism

– Multiple genes are involved in substance abuse

Causes of Substance-Related Disorders: Neurobiological Influences

• Results of Neurobiological Research

– Drugs affect the pleasure or reward centers in the brain

– The pleasure center – Dopamine, midbrain, frontal cortex

– GABA turns off reward-pleasure system

– Neurotransmitters responsible for anxiety/negative affect may be inhibited

Causes of Substance-Related Disorders: Psychological Dimensions

• Role of Positive and Negative Reinforcement

– Most see substance abuse as a means to cope with negative affect

– The self-medication and the tension reduction hypotheses

• Opponent-Process Theory

– Explains why the crash after drug use fails to keep people from using

• Role of Expectancy Effects

– Expectancies influence drug use and relapse

Causes of Substance-Related Disorders: Social and Cultural Dimensions

• Exposure to Drugs in a Prerequisite for Use of Drugs

– Media, family, peers

– Parents and the family appear critical

• Societal Views About Drug Abuse

– Sign of moral weakness – Drug abuse is a failure of self-control

– Sign of a disease – Drug abuse is caused by some underlying process

• The Role of Cultural Factors

– Influence the manifestation of substance abuse

An Integrative Model of Substance-Related Disorders

• Exposure or Access to a Drug Is a Necessary, but not Sufficient

• Drug Use Depends on Social and Cultural Expectations

• Drugs Are Used Because of Their Pleasurable Effects

• Drugs Are Abused for Reasons That Are More Complex

– The premise of equifinality

– Stress may interact with psychological, genetic, social, and learning factors

Figure 10.7

An integrative model of substance related disorders

Biological Treatment of Substance-Related Disorders

• Agonist Substitution

– Safe drug with a similar chemical composition as the abused drug

– Examples include methadone for heroin addiction, and nicotine gum or patch

• Antagonistic Treatment

– Drugs that block or counteract the positive effects of substances

– Examples include naltrexone for opiate and alcohol problems

• Aversive Treatment

– Drugs that make the injection of abused substances extremely unpleasant

– Examples include antabuse for alcoholism and silver nitrate for nicotine addiction

• Efficacy of Biological Treatment

– Such treatments are not generally not effective when used alone

Psychosocial Treatment of Substance-Related Disorders

• Inpatient vs. Outpatient Care

– Data suggest little difference in terms of overall effectiveness

• Community Support Programs

– Alcoholics Anonymous and related groups

– Seem helpful and are strongly encouraged

• Debate Over Controlled Use vs. Complete Abstinence as Treatment Goals

Psychosocial Treatment of Substance-Related Disorders

• Components of Comprehensive Treatment and Prevention Programs

– Individual and group therapy

– Aversion therapy and convert sensitization

– Contingency management

– Community reinforcement

– Relapse prevention

– Preventative efforts via education

Summary of Substance-Related Disorders

• DSM-IV and DSM-IV TR Substance Related Disorders Cover Four Classes

– Depressants, stimulants, opiates, and hallucinogens

– Specific diagnoses include dependence, abuse, intoxication, or withdrawal

• Most Psychotropic Drugs Activate the Dopaminergic Pleasure Pathway in the Brain

• Psychosocial Factors Interact with Biological Influences to Produce Substance Disorders

• Treatment of Substance Dependence Is Largely Unsuccessful

– Highly motivated persons do best when part of combined treatment programs

• Substance-Related Disorders Are 100% Preventable

Summary of Substance-Related Disorders (cont.)

Figure 11.x1 (cont.)Exploring substance-related disorders

Summary of Substance-Related Disorders (cont.)

Figure 11.x2Exploring substance-related disorders, treatment

Summary of Substance-Related Disorders (cont.)

Figure 11.x2 (cont.)Exploring substance-related disorders, treatment

Web sites

• National Clearinghouse for Alcohol and Drug Information– www.health.org

• National Institute on Drug Abuse– www.nida.nih.gov

• Inhalants– www.inhalants.org

• Substance Abuse and Mental Health Services Administration– www.samhsa.gov

Impulse-Control Disorders

• DSM-IV-TR

– Intermittent explosive disorder

– Kleptomania

– Pyromania

– Pathological gambling

– Trichotillomania

Impulse-Control Disorders (continued)

• Each is Characterized by

– Increased tension/anxiety prior to the act

– A sense of relief following the act

– Impairment of social and occupational functioning

Impulse-control Disorders: Intermittent Explosive Disorder

• Intermittent Explosive Disorder

– Rare condition

– Characterized by frequent aggressive outbursts

– Leads to injury and/or destruction of property

– Few controlled treatment studies

Impulse-control Disorders: Kleptomania

• Kleptomania

– Failure to resist urge to steal unnecessary items

– Seems rare, but it is not well studied

– Highly comorbid with mood disorders

– Also co-occurs with substance-related problems

Impulse-control Disorders: Pyromania, Pathological Gambling

• Pyromania– Involves having an irresistible urge to set

fires– Diagnosed in less than 4% of arsonists– Little etiological and treatment research

• Pathological Gambling– Affect 3-5% adult Americans– Treatment is similar to that for substance

dependence

Trichotillomania (continued)

• Trichotillomania

– Inability to resist the urge to pull hair

– Observed in 1-5% of college students, mostly female

– Clomipramine (Anafranil) and CBT have been shown to be helpful