Chapter 11
Conduct Disorder: DSM-V Criteria
A repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms are violated: Manifested by three or more criteria in past 12 months, and at least one in the past six months. Bullies, intimidates, threatens Initiates physical fights Weapon used to harm others Physically cruel to others Cruel to animals Confrontational stealing Forced other into sexual activity Intentional fire setting Deliberate destruction of others property Breaking an entering Lies and cons others to avoid obligations or gain favors (girls) Theft without confronting the victim Curfew violations, prior to age 13 Truant from school, beginning before age 13 years. Run away from home at least twice (or 1 time if lengthy). Severity is ranked as Mild, Moderate or Severe Childhood onset- one criteria before age 10 Adolescent onset- absence of criteria prior to age 10
Oppositional Defiant Disorder: Comorbidity with ADHD
An estimated 3% to 5% of all school age children are affected by its conditions (APA, 1994). ADHD is not caused by poor parenting, food allergies, or excess sugar. Up to 66% of children with ADHD will continue to show symptoms into adulthood It is considered the most diagnosed psychiatric disorder in children and adolescents. Approximately 25% have a specific learning disability
Conduct Disorder
Approximately 6 to 16 percent of boys and 2 to 9 percent of girls meet the diagnostic criteria for Conduct Disorder. The incidence of Conduct Disorder increases from childhood to adolescence (Searight, 2001).
Anabolic-Androgenic Steroids
Derived or synthesized from testosterone Used medicinally or to increase body mass No associated high Rather, dependence involves wanting to maintain the effects of the substance (i.e., increased muscle mass) May cause long-term mood disturbances
Biological Treatment of Substance-Related Disorders
Importantly, it is estimated that fewer than 25% of the people who have significant problems with substance use seek treatment for their problems (Dawson et al., 2005). In order to reach out to these individuals, efforts are under way to put in place routine screenings for substance use problems in settings such as doctor's offices, hospital emergency rooms, and even in college and university health clinics. Agonist substitution Safe drug with a similar chemical composition as the abused drug Examples include methadone 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 use of substances extremely unpleasant Examples include antabuse and silver nitrate Efficacy of biological treatment Generally ineffective when used alone Used to help with withdrawal symptoms
Pyromania
Involves having an irresistible urge to set fires Diagnosed in just 3% of arsonists Little etiological and treatment research Treatment usually focuses on identifying urges and practicing incompatible behaviors
Cannabis-Related Disorders
Marijuana Considered a mild hallucinogen Most frequently used illegal drug: 2.2 M people used in last 30 days in US Active ingredient: Tetrahydrocannabinol (THC) Variable, individual reactions May include euphoria, mood swings, paranoia, hallucinations, reduced concentration Dependence and withdrawal are uncommon Cannabis (marijuana) was the drug of choice in the 1960s and early 1970s. Although it has decreased in popularity, it is still the most routinely used illegal substance, with 5 to 15% of people in western countries reporting regular use (Jager, 2012). In the United States, 22.2 million individuals aged 12 or older used marijuana in the past 30 days (SAMHSA, 2014). Perhaps more than any other drug, however, cannabis can produce different reactions in people. It is not uncommon for someone to report having no reaction to the first use of the drug; it also appears that people can "turn off" the high if they are sufficiently motivated (Jager, 2012). Research on frequent cannabis users suggests that impairments of memory, concentration, relationships with others, and employment may be negative outcomes of long-term use (possibly leading to cannabis use disorders), although some researchers suggest that some psychological problems precede usage—increasing the likelihood that someone will use cannabis (Heron et al., 2013; Macleod et al., 2004). The introduction of synthetic marijuana (referred to with a number of different names such as "fake weed," "K2" or "Spice" and marketed as "herbal incense") has caused alarm because in many places it can be purchased legally and the reaction to its use can be extremely harmful (e.g., hallucinations, seizures, heart rhythm problems, etc.) The most common of these chemicals includes the tetrahydrocannabinols, otherwise known as THC. An exciting finding in the area of cannabis research was that the brain makes its own version of THC, a neurochemical called anandamide after the Sanskrit word ananda, which means "bliss" (Sedlak & Kaplin, 2009; Volkow, Baler, Compton, & Weiss, 2014). Subsequent research points to several other naturally-occurring brain chemicals including 2-AG (2-arachidonylglecerol), noladin ether, virodhamine, and N-arachidonoyldopamine (Mechoulam & Parker, 2013; Piomelli, 2003). Scientists continue to explore how this neurochemical affects the brain and behavior (Piomelli, 2014).
Comorbidity with ADHD: ODD vs ADHD
ODD Refuses to comply with requests Easily annoyed or annoys others on purpose Loses Temper Often angry and resentful ADHD Doesn't seem to listen Poor follow through on directions Difficulty waiting turn Impulsive Interrupts and intrudes Forgetful Easily distracted Talks excessively
Comorbidity: ODD and Depression
ODD Loses Temper Often angry and resentful Touchy or easily annoyed Depression Psychomotor agitation Irritable mood Poor concentration and indecisiveness. Insomnia or hypersomnia
Sedative, Hypnotic, or Anxiolytic-Related Disorders
The nature of drugs in this class Sedatives - calming (e.g., barbiturates) Hypnotic - sleep inducing Anxiolytic - anxiety reducing (e.g., benzodiazepines) Have generally tranquilizing effects Act on GABA receptors in the brain Abusers more likely to be female, Caucasian, 35+ Effects are similar to large doses of alcohol Combining such drugs with alcohol is synergistic and dangerous DSM-5 criteria for this class of disorders Like other substance use disorders: Use leading to significant interference or distress and accompanied by problems such as reduced activities or tolerance Benzodiazepines (which today include Valium, Xanax, and Ativan) have been used since the 1960s, primarily to reduce anxiety. These drugs were originally touted as a miracle cure for the anxieties of living in our highly pressured technological society. Although in 1980 the U.S. Food and Drug Administration ruled that they are not appropriate for reducing the tension and anxiety resulting from everyday stresses and strains, an estimated 85 million prescriptions are written for benzodiazepines in the United States each year (Olfson, King, & Schoenbaum, 2015). In general, benzodiazepines are considered much safer than barbiturates, with less risk of abuse and dependence. Reports on the misuse of Rohypnol, however, show how dangerous even some benzodiazepine drugs can be. Rohypnol (otherwise known as "forget-me-pill," "roofenol," "roofies," "ruffies") gained a following among teenagers in the 1990s because it has the same effect as alcohol without the telltale odor. There have been numerous incidents of men giving the drug to women without their knowledge, however, making it easier for them to engage in date rape . Larger doses can have results similar to those of heavy drinking: slurred speech and problems walking, concentrating, and working. At extremely high doses, the diaphragm muscles can relax so much that they cause death by suffocation. Overdosing on barbiturates is a common means of suicide. The DSM-5 criteria for sedative-, hypnotic-, and anxiolytic-related disorders do not differ substantially from those for alcohol disorders. Both include maladaptive behavioral changes such as inappropriate sexual or aggressive behavior, variable moods, impaired judgment, impaired social or occupational functioning, slurred speech, motor coordination problems, and unsteady gait. Sedative, hypnotic, and anxiolytic drugs affect the brain by influencing the GABA neurotransmitter system (Bond & Lader, 2012), although by mechanisms slightly different from those involving alcohol. As a result, when people use alcohol with any of these drugs or combine multiple types there can be synergistic effects. In other words, if you drink alcohol after taking a benzodiazepine or barbiturate or combine these drugs, the total effects can reach dangerous levels. Barbiturate use has declined and benzodiazepine use has increased since 1960 (SAMHSA, 2012). Of those seeking treatment for substance-related problems, less than 1% present problems with benzodiazepines compared with other drugs of abuse. Those who do seek help with abuse of these drugs tend to be female, Caucasian, and over the age of 35.
Oppositional Defiant Disorder
They can be deceitful and manipulative, usually causing others to become easily annoyed with their limit-testing behavior. "Children with this disorder ignore or openly defy adults' rules and requests, finding 50 ways to annoy others" (Maxmen & Ward, 1995).
ODD- DSM-V Criteria
To meet DSM-V criteria, certain factors must be taken into account. First, the defiance must interfere with the child's ability to function in school, home, or the community. Second, the defiance cannot be the result of another disorder, such as depression, anxiety, or the more serious Conduct disorder. Third, the child's problem behaviors have been happening for at least six months. The diagnostic criteria for this disorder are as follows: Often loses temper This is one of the most difficult behaviors for authority figures to deal with in working with these clients. One must keep in mind that if we lose our temper with them, we have confirmed the very thing they expected from us. Is often touchy or easily annoyed by others It may not take much to annoy these individuals. It can be something as simple as not paying attention to their demands or a rolling of the eyebrows. Often actively defies or refuses to comply with requests or rules This is one of the trademarks of these clients. Often, they lie in wait to challenge the rules and authority of those in control. These clients tend to defy requests of authority figures openly, awaiting an attack or challenge from the authority figure. Is often angry and resentful The anger is used as a weapon and a defense mechanism. Sometimes it is a learned behavior, as the child grew up or lives in a home in which the expression of anger is acceptable, a part of their upbringing, and/or a secondary emotion. Careful attention to the true feelings behind the anger must be acknowledged to help these individuals. Annoys others on purpose This is possibly one of the most misunderstood aspects of these clients diagnostic picture. It becomes difficult for authority figures and others to deal with. One cannot understand why the adolescent or child deliberately attempts, and succeeds in annoying others to the point of frustration. Often loses temper This is an example of the cross-correlation with Depression and Dysthymia, as irritable mood is common in childhood Depression. Additionally, losing ones temper can be used as an avoidance technique. Often argues with adults One is more apt to argue if ones mood is already unstable. The adage that it takes two to argue must be taken into account when dealing with these clients. Parents of these children often verbalize an inability to fight anymore with these clients. Often blames others for his or her mistakes or misbehavior This behavior is within the realm of irresponsibility. The children and young adults that have an ingrained pattern of blaming may have a tendency to become more prone to criminal behavior, justifying their actions and blaming others for their plight. Spiteful or vindictive "Misery loves company." These clients are often hurting inside and have been hurt by others. Thus, they are sometimes subconsciously acting out the very pain they feel onto others. Additionally, they may feel as if they have been wronged, and may feel the only way to rectify or remedy the situation is to "get back" at the other person(s). To qualify for ODD, the behaviors must occur more frequently than is typically observed in same age individuals. Additionally, the behavior must lead to significant impairment in social, academic, or occupational functioning. Diagnosis not made if exclusive to Mood Disorder or Conduct Disorder
An Integrative Model of Substance-Related Disorders
Exposure or access to a drug is necessary, but not sufficient Drug use depends on: Social and cultural expectations Positive and negative reinforcement Genetic predisposition and biological factors Psychosocial stressors
Causes of Substance-Related Disorders: Social and Cultural Dimensions
Exposure to drugs is a prerequisite for use of drugs Media, family, peers can influence exposure to drugs Parents and the family appear critical Societal views about drug abuse Sign of moral weakness - failure of self-control Sign of a disease - caused by some underlying process The role of cultural factors Influence the manifestation of substance abuse Some cultures expect heavy drinking at certain social occasions (e.g., Korea) Cultural expectancies of substances may influence drug-related behavior If drinking is thought to increase aggressiveness, people may act in more aggressive ways after drinking
Causes of Substance-Related Disorders: Psychological Dimensions
Early on, drug use may be seeking a euphoric high (positive reinforcement) Later, drug use will be seeking escape from withdrawal/crash (negative reinforcement) Substance abuse as a means to cope with negative affect Self-medication, tension reduction Drugs offer escape from life stressors Opponent-process theory Drugs themselves are easiest way to alleviate feelings of withdrawal Cognitive factors Role of expectancy effects: People use drugs when they anticipate positive effects Cravings Triggered by cues (mood, environment, availability of drug)
Intoxication
Our physiological reaction to ingested substances—drunkenness or getting high—is substance intoxication. For a person to become intoxicated, many variables interact, including the type of drug taken, the amount ingested, and the person's individual biological reaction.
Common Interventions and Treatment Issues LaGreca and Santogrossi (1980) proposed a program that targets nine behaviors:
1) Smiling 2) Greeting 3) Joining 4) Inviting 5) Conversing 6) Sharing 7) Cooperating 8) Complimenting 9) Grooming
Progression of Alcohol Related Disorders
20% are able to stop drinking on their own Dependence usually develops over time, but course may be variable Those who start drinking at age 11 or earlier are at higher risk for chronic or severe alcohol use disorders Alcohol and violence Drinking does not cause violence, but may increase the likelihood of impulsive behavior Research on the mechanism responsible for the differences in early alcohol use suggests that one's response to the sedative effects of the substance affects later use. In other words, those individuals who tend not to develop the slurred speech, staggering, and other sedative effects of alcohol use are more likely to abuse it in the future (Chung & Martin, 2009; Schuckit, 2014a). This is of particular concern given the trend to mix highly caffeinated energy drinks with alcohol
Conduct Disorder: Common Interventions and Treatment Issues
Bloomquist and Schnell concluded, "clinic therapy has not been demonstrated as effective"... (research indicates) "the need for practitioners to have a multi faceted effort when treating ODD youngsters" (2002). According to research by the American Academy of Child and Adolescent Psychiatry (1997) and the American Psychological Association (1998), the most efficacious interventions for children with ODD, CD and ADHD are: Parent Training Research indicates that "parents of conduct disordered children have an underlying deficit in certain fundamental parenting skills" (Hersen and Ammerman, 2000). Social competence training procedures emphasizing problem solving and anger management Social skills training has proven highly effective in treating a number of child and adolescent behavior problems (Gilbert & Gilbert, 1991). Providers should have smaller caseloads, be afforded more time to plan for sessions, have considerable experience, and should measure outcomes. Behavioral classroom management Brestan and Eyberg (1999), state parent training, anger management, and social competence training are "probably efficacious for this group of children". Hersen and Ammerman state that "several prominent strategies are emphasized as a means of preventing child conduct problems,(such as) developing prosocial rather than antisocial behaviors' (2000, p. 399).
Conduct Disorder: Etiology
Conduct disorder has both genetic and environmental components. Youth with conduct disorder appear to have deficits in processing social information or social cues, and some may have been rejected by peers as young children. Children with conduct disorder experience deficits in social problem solving skills. As a result they generate fewer alternate solutions to social problems, seek less information, see problems as having a hostile basis, and anticipate fewer consequences than children who do not have a conduct disorder (Webster-Stratton & Dahl, 1995). Maternal depression, paternal alcoholism and/or criminalism and antisocial behavior in either parent have been specifically linked to the disorder. Webster-Stratton and Dahl (1995) suggested that depressed and irritable mothers indirectly cause behavior problems in their children through inconsistent limit setting, emotional unavailability, and reinforcement of inappropriate behaviors through negative attention. Caregivers, particularly those with psychiatric conditions and substance abuse problems, may respond to these children coercively and inconsistently As a result, children with conduct disorder do not experience a consistent relationship between their behavior and its consequences. Johnson (et. al. 2002) concluded, "peer rejection and aggression independently predict later conduct problems, and that these patterns can be detected reliably as early as third grade". Children who suffer from early peer rejection are more likely to be bullied, disruptive in class, and socially aggressive in interactions (Bassarath, 2001).
Components of Effective Classroom Management (Bloomquist and Schnell, 2002)
Create an accepting and supportive classroom climate Utilize effective instructional practices Promote social and emotional skills Effectively manage common problem times: transitions and seatwork Establish and teach clear rules and procedures Involve parents Monitor child behavior Respond to mild problem behavior with a consistent procedure Effectively manage angry/acting out behavior Utilize mild punishment effectively Utilize rewards effectively Rewards must be used in conjunction with consequences and punishment. Common classroom examples include: Computer time Homework pass Watching a DVD Listening to music Free time Extra recess Media center time School supplies Class party Group games in gym Good note home. Bloomquist and Schnell (2002) speak of social competence training, which provides direct instruction and coaching to promote development of overt social behaviors. Areas of teaching include: Affective education Self-monitoring Anger management training Communication skills training Social perspective taking training "Youngsters respond positively when a comfortable and supportive climate is fostered. This entails teachers and child care staff expressing an interest in each youth beyond the narrow subject matter" (Pazaratz, 1998). Role playing, discussion, games and stories are also used as tools to facilitate the healing process. By using these strategies with the previously mentioned intervention areas intervening areas, practitioners increase the odds of successful outcomes.
Stimulants: Amphetamine Use Disorders
Effects of amphetamines Produce elation, vigor, reduce fatigue Such effects are usually followed by extreme fatigue and depression Amphetamines stimulate CNS by Enhancing release of norepinephrine and dopamine Reuptake is subsequently blocked Some ADHD drugs are mild stimulants E.g., Adderall, Ritalin Cocaine Methamphetamine Ecstasy (MDMA) Amphetamine effects, but without the crash Crystal meth Purified form of amphetamine May cause aggressive tendencies in addition to high Extreme risk of dependence DSM-5 diagnostic criteria for intoxication in amphetamine use disorders include significant behavioral symptoms, such as euphoria or affective blunting (a lack of emotional expression), changes in sociability, interpersonal sensitivity, anxiety, tension, anger, stereotyped behaviors, impaired judgment, and impaired social or occupational functioning. After cocaine and methamphetamine, MDMA is the club drug most often bringing people to emergency rooms, and it has passed LSD in frequency of use (SAMHSA, 2011). A purified, crystallized form of amphetamine, called methamphetamine (commonly referred to as "crystal meth" or "ice"), is ingested through smoking. This drug causes marked aggressive tendencies and stays in the system longer than cocaine, making it particularly dangerous. Amphetamines stimulate the central nervous system by enhancing the activity of norepinephrine and dopamine. Specifically, amphetamines help the release of these neurotransmitters and block their reuptake, thereby making more of them available throughout the system (Carvalho et al., 2012). Too much amphetamine—and therefore too much dopamine and norepinephrine—can lead to hallucinations and delusions.
Stimulants: Caffeine-Related Disorders
Effects of caffeine - the "gentle" stimulant Used by over 85% 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-5 Criteria for Caffeine Intoxication Recent caffeine consumption, possibly in excess Associated with physical symptoms including restlessness, anxiety, insomnia, flushed face, diuresis, GI disturbance, muscle twitching, rambling thoughts or speech, elevated or irregular heartbeat, excitement, inexhaustibility, motor agitation Symptoms cause clinically significant distress or impairment In larger doses, it can make you feel jittery and can cause insomnia. Because caffeine takes a relatively long time to leave our bodies (about 6 hours), sleep can be disturbed if the caffeine is ingested in the hours close to bedtime. This effect is especially pronounced among those already suffering from insomnia DSM-5 includes caffeine use disorder—defined problematic caffeine use that causes significant impairment and distress—as a condition for further study (American Psychiatric Association, 2013).
Alcohol-Related Disorders: Chronic Use
Effects of chronic alcohol use Intoxication Withdrawal Delirium tremens - hallucinations and tremors brought on by withdrawal from severe alcohol use Fetal alcohol syndrome - problems in fetus from alcohol use during pregnancy Impaired growth, cognitive difficulties, behavioral problems Long term heavy alcohol use may lead to: Dementia Wernicke-Korsakoff disorder (confusion, lack of coordination, impaired speech) Whether alcohol will cause organic damage depends on genetic vulnerability, the frequency of use, the length of drinking binges, the blood alcohol levels attained during the drinking periods, and whether the body is given time to recover between binges. More seriously, two types of organic brain syndromes may result from long-term heavy alcohol use: dementia and Wernicke-Korsakoff syndrome. Dementia, (or neurocognitive disorder), which we discuss more fully in Chapter 15, involves the general loss of intellectual abilities and can be a direct result of neurotoxicity or "poisoning of the brain" by excessive amounts of alcohol (Ridley, Draper, & Withall, 2013). Wernicke-Korsakoff syndrome results in confusion, loss of muscle coordination, and unintelligible speech (Isenberg-Grzeda, Kutner, & Nicolson, 2012); it is believed to be caused by a deficiencyof thiamine, a vitamin metabolized poorly by heavy drinkers. Among children with FAS, beta-3 ADH may be prevalent according to new research. Beta-3 ADH is also found most often in African Americans. What these two findings suggest is that, in addition to the drinking habits of the mother, the likelihood a child will have FAS may depend on whether there is a genetic tendency to have certain enzymes. Children from certain racial groups may thus be more susceptible to FAS than are others.
Stimulants: Cocaine-Related Disorders
Effects of cocaine Short-lived sensations of elation, vigor, reduced fatigue Effects result from blocking the reuptake of dopamine Highly addictive, but addiction develops slowly 1.5 million report use in US each year Most cycle through patterns of tolerance and withdrawal Withdrawal characterized by apathy and boredom > leads to desire to use again Black individuals account for close to half of admissions to emergency rooms for cocaine-related problems (47%) followed by white individuals (37%)and Hispanic individuals (10%) Men were twice as likely as women to be in the emergency room Approximately 17% of cocaine users have also used crack cocaine We saw that alcohol can damage the developing fetus. It has also been suspected that the use of cocaine (especially crack) by pregnant women may adversely affect their babies. Crack babies appear at birth to be more irritable than normal babies and have long bouts of high-pitched crying. They were originally thought to have permanent brain damage, although recent research suggests that the effects are less dramatic than first feared (Buckingham-Howes, Berger, Scaletti, & Black, 2013; Schiller & Allen, 2005). Some work suggests that many children born to mothers who have used cocaine during pregnancy may have decreased birth weight and decreased head circumference, and are at increased risk for later behavior problems (Richardson, Goldschmidt, & Willford, 2009). Complicating the evaluation of children born to mothers who use cocaine is that their mothers almost always used other substances as well, including alcohol and nicotine. Many of these children are raised in disrupted home environments, which further complicates the picture (Barthelemy et al., 2016). Continuing research should help us better understand the negative effects of cocaine on children. Cocaine enters the bloodstream and is carried to the brain. There the cocaine molecules block the reuptake of dopamine. As you know, neurotransmitters released at the synapse stimulate the next neuron and then are recycled back to the original neuron. Cocaine seems to bind to places where dopamine neurotransmitters reenter their home neuron, blocking their reuptake. The dopamine that cannot be taken in by the neuron remains in the synapse, causing repeated stimulation of the next neuron. This stimulation of the dopamine neurons in the "pleasure pathway" (the site in the brain that seems to be involved in the experience of pleasure) causes the high associated with cocaine use.
Stimulants: Nicotine-Related Disorders
Effects of nicotine Stimulates nicotinic acetylcholine receptors in CNS Results in sensations of relaxation, wellness, pleasure Highly addictive Relapse rates equal to those seen with alcohol and heroin Nicotine users dose themselves to maintain a steady state of nicotine Smoking has complex relationship to negative affect Appears to help improve mood in short-term Depression occurs more in those with nicotine dependence Today, about 20% of all people in the United States smoke, which is down from the 42.4% who were smokers in 1965 (Litvin et al., 2012). DSM-5 does not describe an intoxication pattern for tobacco-related disorders. Rather, it lists withdrawal symptoms, which include depressed mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, and increased appetite and weight gain. Smoking has been linked with signs of negative affect, such as depression, anxiety, and anger (Rasmusson, Anderson, Krishnan-Sarin, Wu, & Paliwal, 2006). For example, many people who quit smoking but later resume report that feelings of depression or anxiety were responsible for the relapse (Kahler, Litvin Bloom, Leventhal, & Brown, 2015). Due to this association between smoking and symptoms of depression and anxiety, relapse may be especially higher for women as compared to men, because women more than men tend to have these symptoms
Hallucinogen-Related Disorders
Hallucinations = altered sensory perceptions (e.g., seeing or hearing things that are not present) Hallucinogens can also produce delusions, paranoia Examples of hallucinogens: LSD (most common), psilocybin, mescaline, PCP Tolerance builds quickly, but resets after brief periods of abstinence LSD (d-lysergic acid diethylamide), sometimes referred to as "acid," is the most common hallucinogenic drug. It is produced synthetically in laboratories, although naturally occurring derivatives of this grain fungus (ergot) have been found historically. The DSM-5 diagnostic criteria for hallucinogen intoxication are similar to those for cannabis: perceptual changes such as the subjective intensification of perceptions, depersonalization, and hallucinations. Physical symptoms include pupillary dilation, rapid heartbeat, sweating, and blurred vision (American Psychiatric Association, 2013). People do report having "bad trips"; these are the sort of frightening episodes in which clouds turn into threatening monsters or deep feelings of paranoia take over. Usually someone on a bad trip can be "talked down" by supportive people who provide constant reassurance that the experience is the temporary effect of the drug and it will wear off in a few hours (Parrott, 2012). Hallucinogens seem to affect the brain in diverse and non-specific ways, meaning by affecting multiple different receptors at one time in opposing ways. It is thought that this broad impact on brain receptors may lead to consciousness expanding experienced by some (Passie & Halpern, 2015).
Gambling Disorder
New disorder in DSM-5 Classified under "Addictive Disorders" Recurrent gambling leading to clinically significant distress or impairment Genetic research shows strong similarities in the biological origins of gambling disorders and substance use disorders Associated with 4+ symptoms within a year: difficulty stopping/reducing gambling restlessness/irritability when trying to cut back need to gamble with increasing amounts of money frequent preoccupation Associated with 4+ symptoms within a year: gambling when distressed attempting to "win it back" after a loss lying about gambling relying on others for financial support jeopardizing a significant relationship/job/opportunity Pathological gamblers often experience cravings similar to people who are substance dependent (Grant, Odlaug, & Schreiber, 2015). Treatment is often similar to substance dependence treatment, and there is a parallel Gambler'sAnonymous that incorporates the same 12-step program we discussed previously. However, the evidence of effectiveness for Gambler's Anonymous suggests that 70% to 90% drop out of these programs and that the desire to quit must be present before intervention (Ashley & Boehlke, 2012). In addition to gambling disorder being included under the heading of "Addictive Disorders," DSM-5 includes another potentially addictive behavior "Internet Gaming Disorder" as a condition for further study (American Psychiatric Association, 2013).
Perspectives on Substance Use Disorders
The nature of substance use disorders Abuse of psychoactive substances Wide-ranging physiological, psychological, and behavioral effects Associated with impairment and significant costs Currently, around 9.7% of the general population (12 years or older) are believed to use illegal drugs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013).
Facts Regarding Disruptive Behavior
The number one reason children are brought into outpatient clinics is due to behavioral problems. Kazdin (1994) estimated that nearly 42% of children taken to outpatient therapists had symptoms related to behavioral problems Projections suggest that fewer than 10% of children with behavioral problems ever receive mental health treatment (Hobbs, 1982, Webster Stratton, 1997). There is a high prevalence of co-morbidity between ADHD and ODD/CD. Estimates range the percent of co-morbidity to be between 25% to 40%. Oppositional Defiant Disorder, Conduct Disorder and Attention Deficit Hyperactivity Disorder are rarely seen alone in an individual. Richman and colleagues for example, found that 67% of children who displayed externalizing problems at age 3 were still aggressive at age 8 (Richman, Stevenson, & Graham, 1982). Other studies have found stability rates of 50-70%. There is strong evidence that 75% of ADHD children with hyperactivity develop behavioral problems including 50% conduct disorder and 21% antisocial behavior (Klein & Mannuzza, 1991). There is some cross correlation of criteria between depression, ODD and conduct disorder, thus making it difficult to differentiate the primary diagnosis. One may actually have equally significant levels of depression that fuel the oppositional, acting out behavior Age of onset of ODD seems to be associated with the development of severe problems later in life, including aggressiveness and antisocial behavior Not all conduct disordered children have a poor prognosis. Studies suggest that less than 50% of the most severe cases become antisocial as adults (Webster-Stratton & Dahl, 1995). There is evidence from research into causes of conduct disorders that indicates that several biological and environmental factors may contribute to the development of disruptive behavior disorders. Some of the factors that contribute to the development of DBD include neurological, biological, school, family, and parent interactional factors.
Psychosocial Treatment of Substance-Related Disorders
Inpatient vs. outpatient care Little difference in effectiveness Community support programs Alcoholics Anonymous (AA) and related groups (e.g., NA) may be helpful; research is mixed Balancing treatment goals Controlled use vs. complete abstinence Component treatment Incorporate several elements such as psychotherapy and contingency management Comprehensive treatment and prevention programs Individual and group therapy Aversion therapy and convert sensitization Contingency management Community reinforcement Relapse prevention Preventative efforts Recent shift away from education approaches Greater enforcement of anti-drug laws Studies suggest that those who are more likely to engage with AA tend to have more severe alcohol use problem and seem to be more committed to abstinence (McCrady & Tonigan, 2015). Thus, AA can be an effective treatment for highly motivated people with alcohol dependence. Research to date has not shown how AA compares to other treatments. However, preliminary evidence shows that AA can be helpful for individuals seeking to achieve total abstinence and may be more cost effective than other treatments. Researchers are still trying to understand exactly why AA and the 12-step program work, but it seems that social support plays an important role Some individuals have a more mixed experience with AA and this includes agnostics and atheists, women, and minority groups (McCrady & Tonigan, 2015). Other groups now exist (e.g., Rational Recovery, Moderation Management, Women for Sobriety, SMART Recovery) for individuals who benefit from the social support of others but who may not want the abstinence-oriented 12-step program offered by groups modeled after AA In the alcoholism treatment field, the notion of teaching people controlled drinking is extremely controversial, partly because of a classic study showing partial success in teaching severe abusers to drink in a limited way During the second year after treatment, those who participated in the controlled drinking group were functioning well 85% of the time, whereas the men in the abstinence group were reported to be doing well only 42% of the time. Although results in the two groups differed significantly, some men in both groups suffered serious relapses and required rehospitalization and some were incarcerated. The results of this study suggest that controlled drinking may be a viable alternative to abstinence for some alcohol abusers, although it clearly isn't a cure. MET is based on the work of Miller and Rollnick (2012), who proposed that behavior change in adults is more likely with empathetic and optimistic counseling (the therapist understands the client's perspective and believes that he or she can change) and a focus on a personal connection with the client's core values (for example, drinking and its consequences interferes with spending more time with family). By reminding the client about what he or she cherishes most, MET intends to improve the individual's belief that any changes made (e.g., drinking less) will have positive outcomes (e.g., more family time) and the individual is therefore more likely to make the recommended changes. MET has been used to assist individuals with a variety of substance use problems, and it appears to be a useful component to add to psychological treatment (e.g., Manuel, Houck, & Moyers, 2012). Cognitive-behavioral therapy (CBT) is an effective treatment approach for many psychological disorders (see Chapter 5, for example) and it is also one of the most well designed and studied approaches for treating substance dependence (Granillo, Perron, Jarman, & Gutowski, 2013).
Risk Factors for ODD and Conduct Disorder: School Related Factors
A bidirectional relationship exists between academic performance and conduct disorder. Frequently children with conduct disorder exhibit low intellectual functioning and low academic achievement from the outset of their school years (White, Moffit, Earls, and Robins, 1990). Delinquency rates and academic performance appear correlated to characteristics of the school setting itself. Teacher availability Teacher use of praise Emphasis placed on individual responsibility Emphasis on academic work Student teacher ratio
DSM-5 Criteria for Tobacco Withdrawal
After several weeks of daily use, unpleasant symptoms upon stopping or reducing: Insomnia, increased appetite, restlessness, trouble concentrating, anxiety and depression, irritability Symptoms lead to clinically significant distress or impairment
Relapse Prevention for Substance-Related Disorders
Cognitive-behavioral approach to learn habits that make relapse less likely Address distorted cognitions Identify negative consequences Increase motivation to change Identify high risk situations Reframe relapse Failure of coping skills, not person
Five Main Categories of Substances
Depressants: These substances result in behavioral sedation and can induce relaxation. They include alcohol (ethyl alcohol) and the sedative and hypnotic drugs in the families of barbiturates (for example, Seconal) and benzodiazepines (for example, Valium, Xanax). Stimulants: These substances cause us to be more active and alert and can elevate mood. Included in this group are amphetamines, cocaine, nicotine, and caffeine. Opiates: The major effect of these substances is to produce analgesia temporarily (reduce pain) and euphoria. Heroin, opium, codeine, and morphine are included in this group. Hallucinogens: These substances alter sensory perception and can produce delusions, paranoia, and hallucinations. Cannabis and LSD are included in this category. Other drugs of abuse: Other substances that are abused but do not fit neatly into one of the categories here include inhalants (for example, airplane glue), anabolic steroids, and other over-the-counter and prescription medications (for example, nitrous oxide). These substances produce a variety of psychoactive effects that are characteristic of the substances described in the previous categories.
Causes of Substance-Related Disorders: Neurobiological Influences
Drugs affect the "pleasure pathway" of the brain (i.e., the area that is active when receiving a reward such as food) Believed to include dopaminergic system in areas of the midbrain and frontal cortex Drugs may inhibit GABA, which turn off reward-pleasure system Drugs inhibit neurotransmitters that produce anxiety/negative affect Other drugs, however, appear to increase the availability of dopamine in more roundabout and intricate ways. For example, the neurons in the brain's ventral tegmental area are kept from continuous firing by GABA neurons. (Remember that the GABA system is an inhibitory neurotransmitter system thatblocks other neurons from sending information.) One thing that keeps us from being on an unending high is the presence of these GABA neurons, which act as the "brain police," or superegos of the reward neurotransmitter system. Opiates (opium, morphine, heroin) inhibit GABA, which in turn stops the GABA neurons from inhibiting dopamine, which makes more dopamine available in the brain's pleasure pathway.
Other Drugs of Abuse: Designer Drugs
Drugs were originally produced by pharmaceutical companies to target diseases; then others began producing for recreational use Cause drowsiness, pain relief and dissociative sensations Ecstasy/Molly BDMPEA ("nexus") Ketamine ("Special K") Synthetic Cathinones ("bath salts")
Impulse-Control Disorders
Each is characterized by: Impairment of social and occupational functioning May also involve increased tension/anxiety prior to the act, pleasurable anticipation, or a sense of relief following the act Include: Intermittent explosive disorder Kleptomania Pyromania
Treatment Issues: Relationship with Students
Gabbard (1992) spoke of the therapeutic responses from clinical staff "are central healing factors in the milieu...follow up interviews of discharged patients occasionally discovered that certain patients found a member of the housekeeping staff, the grounds crew, or the food service to be a key person in the healing process".
Etiology Factors
Genetic Vulnerability: Genetic predisposition plays a role in the initial expression of aggression and conduct problems in many children. Robins (1996) found that the presence of antisocial behavior in parents is associated with an increased probability of antisocial and delinquent behavior in children. According to Fincham (1994), disruptive adolescents typically grew up families characterized by a low level of cohesion and a lack of mutual emotional support, nurturance, and protection. This lack of involvement with each other seems to result in high tolerance for deviance, such as antisocial behavior. Some studies suggest executive functioning deficits (frontal lobe, emotional/ behavioral regulation) are correlated to ACP. Executive functioning is not a unitary process...it denotes one's ability to set shift, problem solve, interference control abilities, working memory, inhibition and planning. Several studies suggest executive functioning deficits correlate with conduct disorder and juvenile delinquency (Teichner & Golden, 2000). Hughes et al (1998) found oppositional preschoolers had problems on executive planning tasks, even with ADHD symptoms controlled.
Other Drugs of Abuse: Inhalants
Highest use during early adolescence Found in volatile solvents Breathed into the lungs directly Rapid absorption Examples: spray paint, hair spray, paint thinner, gasoline, nitrous oxide Effects similar to alcohol intoxication Produce tolerance and prolonged withdrawal symptoms Several negative physiological effects (e.g., organ damage) Inhalant use is highest during early adolescence, ages 13 to 14, especially in those in correctional or psychiatric institutions. Additionally, higher rates of inhalant use are found among Native Americans and Caucasians, as well as those who live in rural or small towns, come from disadvantaged backgrounds, have higher levels of anxiety and depression, and show more impulsive and fearless temperaments
Conduct Disorder: Gender
It has been speculated that parental psychological status has more of an influence on girls than on boys because of girls' socialization in the family (Webster-Stratton, 1996). Behaviors that are internally focused are more common in girls and include anxiety, shyness, withdrawal, hypersensitivity, and physical complaints.
Kleptomania
Kleptomania Failure to resist urge to steal unnecessary items Disorder may be more common in women than in men Typically starts in adolescence Highly comorbid with mood disorders Also co-occurs with substance-related problems There appears to be high comorbidity between kleptomania and mood disorders, and to a lesser extent with substance abuse and dependence (Grant et al., 2010). Some refer to kleptomania as an "antidepressant" behavior, or a reaction on the part of some to relieve unpleasant feelings through stealing (Fishbain, 1987). To date, few reports of treatment exist, and these involve either behavioral interventions or use of antidepressant medication. In one exception, naltrexone—the opioid antagonist used in the treatment of alcoholism—was somewhat effective in reducing the urge to steal in persons diagnosed with kleptomania
Stimulants: An Overview
Most widely consumed drugs in the United States Increase alertness and increase energy Examples include amphetamines, cocaine, nicotine, and caffeine DSM-5 criteria for stimulant intoxication: significant impairment or psychological changes Accompanied by physical changes (e.g., change in HR/BP, dilated pupils, weight loss, vomiting, weakness, chills)
Statistics on Use and Abuse by Race
On the other hand, about half of all Americans over the age of 12 report being current drinkers of alcohol, and there are considerable differences among people from different racial and ethnic backgrounds (see Figure 11.3; SAMHSA, 2012). Caucasians report the highest frequency of drinking (56.8%); drinking is lowest among Asians (40.0%). Again, there are racial differences, with Asians reporting the lowest level of binge drinking (12.4%) and Caucasians (24.0%) and Hispanics or Latinos (24.1%) reporting the highest. Age seems to also be important given that peak lifetime alcohol use happens around late teens to early adolescence. I
Risk Factors for ODD and Conduct Disorder
Parental Conflict and Violence Spousal Physical Aggression Child Rearing Disagreements Marital aggressive behavior Family Life Stressors: Poverty Unemployment Crowded living conditions Illness Single parenthood Community violence Poor supervision Lack of strong family support system Parent-Child Interactions: Coercive process, whereby children learn to escape or avoid parental criticism by escalating their negative behaviors Critical discipline Lack of school involvement Young mothers: High school dropout/lack education Higher substance abuse rates Affiliation with deviant peers Exposure/social learning aspect of relationship
Substance Use Disorders in DSM-5
Pattern of substance use leading to significant impairment and distress Symptoms (need 2+ within a year) Taking more of the substance than intended Desire to cut down use Excessive time spent using/acquiring/recovering Craving for the substance Role disruption (e.g. can't perform at work) Interpersonal problems Pattern of substance use leading to significant impairment and distress Symptoms (need 2+ within a year) Reduction of important activities Use in physically hazardous situations (e.g. driving) Keep using despite causing physical or psychological problems Tolerance Withdrawal DSM-5 now spells out criteria for: Substance intoxication for different types of substances (e.g., alcohol, stimulants) Substance use disorders for different types of substances Withdrawal from different types of substances
Pharmacological Issues and Theoretical Views
Pharmacotherapy may be considered as an adjunct treatment for conduct disorder and comorbid conditions. While there are no formally approved medications for conduct disorder, pharmacotherapy may help specific symptoms (Campbell, et. al, 1995). Current research focuses on defining neurotransmitters that play a role in aggression, with serotonin most strongly implicated. SSRIs may be particularly helpful in treating children with conduct disorder and comorbid major depression. Fluoxetine (Prozac) also was associated with a significant reduction in impulsive-aggressive behavior in adults with personality disorder
The Depressants: Alcohol-Related Disorders
Psychological and physiological effects of alcohol Central nervous system depressant Influences several neurotransmitter systems Specific target is GABA Increases inhibitory effects - makes neural cells worse at firing Alcohol influences a number of neuroreceptor systems, which makes it difficult to study (Ray, 2012). For example, the gamma-aminobutyric acid (GABA) system, which we discussed in Chapters 2 and 5, seems to be particularly sensitive to alcohol. GABA, as you will recall, is an inhibitory neurotransmitter. Its major role is to interfere with the firing of the neuron it attaches to. Because the GABA system seems to affect the emotion of anxiety, alcohol's antianxiety properties may result from its interaction with the GABA system. The glutamate system is under study for its role in the effects of alcohol. In contrast to the GABA system, the glutamate system is excitatory, helping neurons fire. It is suspected to involve learning and memory, and it may be the avenue through which alcohol affects our cognitive abilities. Blackouts, the loss of memory for what happens during intoxication, may result from the interaction of alcohol with the glutamate system.
Gambling Disorder: Treatment
Psychosocial treatment similar to substance abuse Cognitive-behavioral interventions help reduce the symptoms of gambling disorder Brief and full course treatments have both been found to help and both are recommended. Motivation to get better is critical; dropout is high Research is limited, but multipart CBT interventions are under investigation Scheduling alternative activities, setting financial limits, relapse prevention
Intermittent explosive disorder
Rare condition Characterized by frequent aggressive outbursts Leads to injury and/or destruction of property Few controlled treatment studies In a rare but important large study of more than 9,000 people, researchers found that the lifetime prevalence of this disorder was 7.3% (Kessler et al., 2006). Research is at the beginning stages for intermittent explosive disorder and focuses on the brain regions involved as well as the influence of neurotransmitters such as serotonin and norepinephrine and testosterone levels, along with their interaction with psychosocial influences (stress, disrupted family life, and parenting styles). Recent studies have proposed that there is a disruption of the orbital frontal cortex's role ("the executive parts" of the brain) in inhibiting amygdala activation (the "emotional part" of the brain) combined with changes in the serotonin system in those with this disorder (Yau et al., 2015). These and other influences are being examined to explain the origins of this disorder (Coccaro, 2012). Cognitive-behavioral interventions (for example, helping the person identify and avoid "triggers" for aggressive outbursts) and approaches modeled after drug treatments appear the most effective for these individuals, although few controlled studies yet exist (McCloskey, Noblett, Deffenbacher, Gollan, & Coccaro, 2008).
Causes of Substance-Related Disorders: Family and Genetic Influences
Results of family, twin, adoption, and other genetic studies Substance abuse has a genetic component Example: certain genes confer risk for heroin abuse in Latino and Black populations Much of the focus has been on alcoholism Genetic differences in alcohol metabolism > impact which drugs are most effective for treating alcohol use disorders Multiple genes are involved in substance abuse
Assessment
Strong assessment tools include: Diagnostic Interview Conners Parent/Teacher Rating Scales Youth Self Report/Child Behavior Checklist Teachers Rating Scale Child Depression Inventory Perceived Competence Scale Personality Inventories: MACI and MMPI-A Intelligence Testing: WAIS-IV, Woodcock-Johnson Speech and Language Evaluations
Substance-Related Disorders: Terms and Definitions
Substance use Taking moderate amounts of a substance in a way that doesn't interfere with functioning Substance intoxication Physical reaction to a substance (e.g., being drunk) Substance Use Disorder Use in a way that is dangerous or causes substantial impairment (e.g., affecting job or relationships) Substance dependence/Addiction At least two symptoms in the last year that interfered with his/her life or bother him/her a great deal Substance dependence May be defined by tolerance and withdrawal Sometimes defined by drug-seeking behavior (e.g., spending too much money on substance) Tolerance Needing more of a substance to get the same effect / reduced effects from the same amount Withdrawal Physical response when substance is discontinued after regular use
Diagnostic Issues
The DSM-5 term substance-related disorders include 11 symptoms that range from relatively mild (e.g., substance use results in a failure to fulfill major role obligations) to more severe (e.g., occupational or recreational activities are given up or reduced because of substance use). DSM-5 removed the previous symptom that related to substance-related legal problems and added a symptom that indicates the presence of craving or a strong desire to use the substance (Dawson et al., 2012). Substance use might occur concurrently with other disorders for several reasons. Substance-related disorders and anxiety and mood disorders are highly prevalent in our society and may occur together so often just by chance. Drug intoxication and withdrawalcan cause symptoms of anxiety, depression, and psychosis. Disorders such as schizophrenia and antisocial personality disorder are highly likely to include a secondary problem of substance use. However, individuals who were severely depressed before they used stimulants and those whose symptoms persist more than 6 weeks after they stop might have a separate disorder
Substance Use Disorders
The fifth edition of the Diagnostic and Statistical Manual (DSM-5) (American Psychiatric Association, 2013) defines substance use disorders in terms of how significantly the use interferes with the user's life. In order to meet criteria for a disorder, a person must meet criteria for at least two symptoms in the past year that interfered with his/her life or bothered him/her a great deal. When a person has four or five symptoms, he or she is considered to fall in the moderate range. A severe substance use disorder would be someone like Danny that has six or more symptoms. Symptoms for substance use disorders can include a physiological dependence on the drug or drugs, meaning the use of increasingly greater amounts of the drug to experience the same effect (tolerance), and a negative physical response when the substance is no longer ingested (withdrawal) The previous version of the DSM considered substance abuse and substance dependence as separate diagnoses. The DSM-5 combines the two into the general definition of substance-related disorders based on research that suggests the two co-occur
Substance use
The ingestion of psychoactive substances in moderate amounts that does not significantly interfere with social, educational, or occupational functioning.
Conduct Disorder continue
Those with early onset have a worse prognosis and are at higher risk for adult antisocial personality disorder (DSM-IV; Rutter & Giller, 1984; Hendren & Mullen, 1997). Between a quarter and a half of highly antisocial children become antisocial adults Cohen and Flory (1998) found that the singular symptoms of cruelty to people and weapon use best predicted subsequent diagnosis of CD.
Opioids
The nature of opiates and opioids Opiate - natural chemical in the opium poppy with narcotic effects Opioids - natural and synthetic substances with narcotic effects Heroin—used by almost ½ M people in US Illicit use of opium-containing prescriptions is rising—4.13 M people over the age of 12 reporting nonmedical abuse Often referred to as analgesics Analgesic = painkiller Effects of opioids Activate body's enkephalins and endorphins Low doses induce euphoria, drowsiness, and slowed breathing High doses can result in death Withdrawal symptoms can be lasting and severe Mortality rates are high for opioid addicts High risk for HIV infection due to shared needles Research also suggests that individuals who first became addicted to prescription pain medication transitioned to using heroin (Muhuri, Gfroerer & Davies, 2013). People who use opiates face risks beyond addiction and the threat of overdose. Because these drugs are usually injected intravenously, users are at increased risk for other chronic life-threatening illness such as Hepatitis C and HIV infection and therefore AIDS The high or "rush" experienced by users comes from activation of the body's natural opioid system. In other words, the brain already has its own opioids—called enkephalins and endorphins—that provide narcotic effects (Ballantyne, 2012). Heroin, opium, morphine, and other opiates activate this system.
Comorbidity with Depression
The predominant mood in children and adolescents with a depressive disorder can be irritability that may be expressed through angry acting out (Hersen & Ammerman, 2000). Researchers believe that up to one-third of comorbid conduct disordered children may also have a depressive disorder...depressive episodes in children occur most frequently with disruptive behavior disorders (Hersen & Ammerman, 2000).
Antisocial Personality Disorder
Typically, APD is not diagnosed in children; It is reserved for after a person turns 18 years of age. However, a child may have characteristics of APD, which is often the result of data from psychological testing.
Statistics on Use and Abuse
Use Most adults: light drinkers or abstainers Current use = ~50% of Americans drink Binge drinking = 24.6% of Americans had 5+ drinks on one occasion in past month 16.6 million adults ages 18 and older meet criteria for an alcohol use disorder and the same is true of 697, 000 adolescents ages 12 to 17
Preventing Substance-Related Disorders
When done correctly, education can reduce adolescents' use of drugs Education-based approaches (such as DARE) have thus far shown limited efficacy Comprehensive community-based skills programs have promising results Cultural changes may prevent substance use (e.g., social perception of smoking has become less favorable in recent decades)
