chapter 11: substance related and addictive disorders

THE BALANCED PLACEBO DESIGN

???

diagnosis gambling

- 9 feutres, person exhibit 4 of them, 5 are similar to alcohol us, - gabmling with increasingly larger among of money to experience same level of stimulation (tolerance) , agitated or easily annoyed when trying to stop gambling (withdrawal), repeated failed efforts to quit, preccopution, impaired soica/occiaptional funcitiong - less similar to alcohol: chastising losses, frequent gambling with emotional distress, lying to cover it, depending on financial help from others - differences DSM 4/5, illegal acts dropped in DSM-5, rare, not useful - threshold was dropped from 5 to 4 things,

prev of drug/nicotine

- combined lifteime prevalance for abuse/depdence of any controlled substance was 10.3%, - more cmomen in men than women, ' - lifetime prevalence of nicotine dependence was 24%, people who smoke has gone down after link between nicotine and cancer, greater decline among men - overall consumption declined in industrialized countries, increased in developing countries, less educated about health risk - 18-25: smoking rates increased

history of legaltiy

- drinking patterns vary tremendously from one culture to the next and within the same culture form one point in time, views about drinking has changed - more drinking before than now - termpareence: anyone who drank would become drunk, not great arguments, - prohibtion era, eventaully repealed

neuroanatomy/neruochem

- drugs changes in chemical processes of message in the brain - systems involve catecholamnies: dopa, norepi, serotinion, - dopamine and reward pathways - depdent on psychoactive drugs because they stimulate aresas in the brain called reward pathways - medial forebrain bundle: connects ventral tegmental area to nucleus accumbens - connection to frontal/prefrontal cortex, limbo system, amydala, influence of reward - electrical stimulation fo medial forebrain bundle can be powerful source of positive reinforcement for animals in operant condition - natural rewards, food/sex increase dopamine levels in certain crucial sections of this pathways, mesolimbic dopamine pathway - stimulants (ampehtamine, cocaine) affect reward pathways by inhibiting reuptake of dopamine into nerve terminals - brain imaging studies found cocaince increases dopamine concentration in the limbo areas of the brain, and medial prefrontal cortex - medial prefrotnal cortex invovled in drug craving as well - effect of alcohol on pathways are more complex, less understood, stimulate mesolimbic dopamine pathway or may act indirectly by decreasing acitivity of GABA neurons - GABA reception important for alcohol dependence

endogenous opoid peptide

- endorphins: endogenous opids, short chains of amino acids, neuropeptides, narutally synthesize in the brain are closely related to mrophine in their pharmacological properties - opioid chemical affinity for specific report sites, same way that a key fits into a lock - esecpailyl associated with system that control pain, emotion, stress, reared, biological feeding/growth - aniamls tolerance to injections of endorphine - alcoholism and exaggerated activation of the endogenous opioid system in response to alcohol stimulation - opioid recotr antagonist: drugs that block effects of opiod peptides, produce decrease in alcohol self administration in lab animals - when alcohol people take naltrexone, antagonist, drink less alcohol, high is diminished - genetic predsiption toward increased consumption of alcohol high levels of lipid system response to the ingestion of alcohol

gambling symptoms

- gambling disordeR: impaired control of gambling activiites, social impairment that followed from gambling: loos of jobs/relationships) and continued problem behavior in spite of accumulation of harmful consequences - chasing losses: process of trying to win back money that has already been loss, limit for themselves, follow losses by more money, results in greater losses - tolerance withdrawal, compelled to gamble, chasing losses and tolerance effects similar - emotioanl conseuqnecs: restlessness/irritabiltiy and feelings of anger, guilt and depression like withdrawal - phyislgical symptoms: for substance use, - more similar to substance use in loss of control not physiological tolerance/withdraal - intellgient, well educated, copmoletetive peopel - art schlichter: NFL. gambler, treatment unsuccessful, arrested, jailed, forgery, cocaine

hallucinogens and related drugs

- hallucinogens: cause people to experience hallucinations, even at low doses - LSD: similar to serontonin, interacting with serotoninc receptors in the brain - psilocybin: serotonin like, found in mushrooms - mexcaline: norepinphrine, in native american cermonies - MDMA, extasy, syntethic amphetamine derivates, stimulant but also hallucinogen, club drug, raves, tablet, but also could be inhaled/injected, - enhanced mood state, feeling of well being, lasts several hours (gets this effect after half hour), changes in perceptual experiences, distortion of time/space, changes in blood pressure, not able to regulate temperature - phencyclidine PCP: originally a painkiller, relaxation, warmth, numbness, psychotic behavior, delusional thinking, mani excitement, modo changes, crterllized form on leaves, smoked, inject/snort - short term effects: based on subjective experience, hard to know, vidi, occasionally spectaluar visual images, colorful patterns (early stage), later phase: meanginful images of people, animals, places, - occasoinlly frighetinng, panic atacks, "bad trips" talked through the process - not toxic, don't die from LSD overdose, PCP is toxic, coma, convulsions, MDMA: can damage sertonin on a permanent basis and it has been associated with fatalities - long term effects - usually used sporadically - if repeatedly, 2-3 days the effect disappear, don't increase use over time, - people who stop using don't have problems, withdrawal not really a thing, - induced psyhotic beahvior, tigeerr onset of psychosis in those that were already vulnerable, - flashbacks: aftereffects that can occur at unpredictable intervals when drug cleared from symptoms, under stress or used another drug

frequency gambling

- lifetime: 2%, increased with spread of legalized gambling, - men more likely than women

treatment alcohol

- many people don't acknowledge their issues, small number actually seek help, reluctance to seek help - high rate of combority with other mental disorders, challenge, less successful of these people - goal: contrversial: no drinking or less, minimize drug use or also address social/occupational problems - detoxification - removal of drug for 3-6 weeks, difficult, withdrawal, could be more gradual (CNS depressant, alcohol, sedative) stimulant drugs stopped abruptly - given meds like benxo, anticonvulsants, minimizing withdrawal, (controversial) - meds during remission - maintain state of remission, stable, long term abstinence - disulfiram drug that can block chemical breakdown of alcohol, treatment in europe, consume even a little alcohol they will become ill, nausea, stop drinking for this reason, voluntary compliance is poor, stop taking it - naltrexone (revia) antagonist of endogenous opiods that have been found to be useful in treatment of alcohol dependence following detoxification - patients who reecevei this and psychotherapy less likely to relapse than just therapy, drink with it don't feel as high, dampen craving by blocking alcohol's ability to stimulate opiod system, reducing rewarding effects of alcohol rather than inducing illness if person drinks - acamprosate Campral: reduce number of drinking days by 30-50% - increases proportion of people whoa re able to achieve total abstinence, used in congestion with psychological treatment problgram, - SSRIS: long term treatment, small inconsistent effects in reducing drinking among patents who are not depressed - not effective for treatment of people with dual diagnosis of alcohol dependence - self help groups: alcohol anonumous - in all groups in NA, europe, first line of attack, other treatment usually too, - fundamentally spiritual, 12 step program, achnolege powerless, recongisiton, making amends, harsshdip for others - every day for 90 days, meet and talks ith others, - long term follow up difficult, impossibly to employ methods of outcome research: random assigment/placebos, early dropout is high - half of popel leave in less than 3 months - survival rates higher for those who are in AA. 80% of AA remained sober for 2-5 years remain sober for next year - cBT - behaviroal responses that trigger abuse - teaches people to identify and respond more appropriately to circumstances that regularly precipitate drug abuse - coping skills training - training in use of social skills, resist pressure to drink heavily - problem solving procedures, help person both to identify situations that lead to heavy dining and formulate alternative - anger management: drink in response to frustration, learn to express negativity in productive ways - focus on intimation and maintaining problems - cognitvie events: expectaions about effects of alcohol are challenged, more adaptive thoughts are rehearsed, negative thoughts of the self addressed - relapse prevention - maintinaing change after accomplish is hard, slip up, - relapse prevention: applied to all forms of substance use disorder: and bulimia, empshis on events that take place after detox, help addict deal with challenges of life without drugs, more adaptive coping responses, relaxation,s coil skills - abstinence violenation effect: guilt loss of control person feels when they slip up, drinking, drug fafter abstinence - blame themselves, useless hopeless, - realpse heroin: - temporary lapse rather than relapse - short term motivational therapy - fail to recognize severity of problems, motivational interviewing nonconfrtantional procedure that can be used to help eople resolve ambivalence about drugs and make a commitment - recognize inconsistency between behavior and long term goals - discussion of problems, reflect on feedback from others, therapist emphatically respond, - icnrase person's awareness of substance use problem - comprehensive situation and feedback, - how to change, select best method, - help person reduce freuqneyc or intensity of alcohol consumption - for people not yet severe, chronic, reduce freuqnecy/intensity

risk for addiction across life

- older people don't drinks much as younger people - 47% of people in 60s don't drink, - prevalence higher in young adults, lowest in elderly - use of illegal drugs is ingfruqnet among the elderly, - abuse/depdence on prediction drugs, use more legal drugs for elderly, risk for addiction with psychoactive drugs - Ms. E: 80 years old, noticed depressive symptoms drinking ervery day - hard to apply DSM to elderly, drug use is different, less likely to suffer form social/occupational impairment

KORSAKOFF'S SYNDROME (ALCOHOL AMNESTIC DISORDER)

One of the most severe outcomes of substance abuse Symptoms: Memory deficit (most often to recent events) Confabulation (falsification of evnets) May not recognize people or objects that have just seen Fill memory with made up and fanciful tales Occurs following many years of heavy use May be the result of vitamin B deficiency

SOCIAL FACTORS - CULTURAL VARIATION

Studies have shown that alcoholism is less common in Mediterranean cultures/those of Mediterranean descent Very LOW rate of alcoholism in: Muslims Mormons Orthodox Jews

symptoms in book

- 1. patterns of pathological consumption, including impaired control over use of the drug and continued use in spite of mounting problems - 2. consequences that follow a prolonged pattern of abuse, including social and occupational impairments, disruption of important interpersonal relationships and deteriorating medical condition - amount of a drug that a specific person consumes is not a good way to define substance use disorders, because people vary significantly in the amount of any given drug they can consume - one feature involves craven, people who are dependent on the drug say they need to control how they are feeling, relieve negative mood states, or to avoid withdrawal symptoms, psychological dependence - index of craving:a mount of time person spends on taking the drugs, - after drinking heavily for a long period of time, most people with a drinking disorder try to stop, efforts at self control are typically short lived and frail - tolerance: the process through which the nervous system becomes less sensitive to the effects of alcohol or any other drug of abuse - three separate mechanisms: - 1. metabolic tolerance: when repeated exposure to a drug causes the person's liver to proceed more enxumes that are used to metalozse, break down, the drug, drug is metabolized more quickly and the person has to take increasibly larger doses in order to maintain the same level - pharmacodynaimc tolerance: receptors in the brain adapt to continued presence of the drug, neuron may adapt by reducing the number of receptors or by reducing their senseitivyt to the drug, down regulation - beahvioral conditioning mechanisms, cues that are regularly associated with the admisntion of a drug begin to function as conditioned stimuli and elicit a conditioned response that is opposite in direction tot he natural effect of the drug - some drugs more likely to produce a buildup of tolerance, heavy users of opioids, such as her ion, CNS stimulants, cocaine, - withdrawal: refers tot hes symptoms experienced when a person stops using a drug, alcohol is a CNS depressant, and the heavy drinker's system becomes accustomed to functioning in a chronically depressed state, - most serious forms of withdrawal include convulsions and visual, tactical, or auditory hallucinations - alcohol withdrawal delirium in DSM-5 - symptoms of withdrawal vary censurably for different kinds - alcohol withdrawal delirium: induced by withdrawal from alcohol - withdrawal symptoms are also addociated with stimulants, such amphetamine, cocaine, and nicotine, although they are sometimes less pronounced than those associated with alcohol and opoids

prevalnce of alcohol use

- 2/3 males drink regularly, social at least, 25% abstain - 20% men/women will develop serious problem with alcohol - lifteime perevalnat 30% for some form of alcohol use disorder - most common mental disorders - 24% of men/women receive treatments - gender differences: 60% of women drink, fewer develop alcoholism, - men outnumber women 2:1 - rate for women has increased, prelvance still higher in men, rates do not seem to converge - social/biological reasons: culture negative view of intociaiton for women, social disapproval, - biological: standard dose of alcohol will produce higher blodd alcohol level in women than in men - men have a higher average content of body water - women more susceptible to liver disorder too

substance use disorders comorbity

- 47% of people with schizophrenia are affected - 61% of people with bipolar disorder are affected (impulsivity and bad judgment that goes along with bail episodes - 51% of those with a mental disorder have at least one addictive disorder - Many people with three or more disorders have never received any treatment - comorbity is a problem

DSM-5

- 9 classes of drugs - substance use disorders kinds of problems that come to mind when we think of someone addicted to a drug - substance induced disorders: immediate impact of drug or discintioning use (withdrawal) - separate sets of criteria for each class of substances and the problems under those categories - alcohol: alcohol use disorder, alcohol intoxiation, alcohol withdrawal, - caeffiene only substance for which manual does not provide a definition of substance use disorder, only caffeine intoxication and withdrawal - used to be substance dependence vs substance abuse, ubut now just substance use disorder with continuous range of severity - alcohol use disorder: combination of those used to identify dependence and abuse with at least features required for threshold, dependence/abuse not distinct forms of the disorder - 2/11 criteria within 12 month period of time for a diagnosis of alcohol use disorder to be made - severity of disorder also noted, based on number of symptoms that are present: mild, moderate 4-5, severe 6+ - impaired control, persistent and unsuccessful efforts to quit, craving, - social impairment - risky use - pharmacological criteria: tolerance and withdrawal, - specific definitions of each drug, used to be more general but changed it because it was problematic - most of substance use disorders are identical

substance use treatment general

- Detoxification - Interventions vs. Motivational Interviewing - Self-help groups (e.g., Alcoholics Anonymous) - Relapse prevention (coping skills, abstinence violation effect) - Various programs reduce drug use; and relapse is common - Little reason to support one program over another - Better attendance associated with improved outcome (personality?) - People who do stop consumption see improvements in many areas (health, social functioning, work preference)

TWO MAJOR PSYCHOLOGICAL ASPECTS OF ADDICTION

- Impulsivity - Positive reinforcement (take more of drug to reinforce subjective high, reward to take the drug, positive subjective feelings) - Arousal, gratification, pleasure - Compulsivity - Negative reinforcement (take more of drug to avoid negative effects, if you are involved in social contexts that create negative emotions/anxious/sad, if drinking relieves that emotion you are removing a negative stimulus contingent on drinking) - Relief of anxiety, withdrawal impairment

drugs of abuse contd

- LEGAL: - In our society, nicotine, alcohol, and caffeine are available legally without a prescription - Others, like benzodiazepines (e.g., Valium and Xanax) and certain opiates (e.g., morphine and methadone) can be prescribed by a physician - ILLEGAL: - Stimulants (e.g., cocaine, amphetamines) - Opiates (e.g., heroin) - Hallucinogens (e.g., LSD) - Why are some addicting drugs illegal? - It's always been that way? Apparently not (read Licit and Illicit Drugs (1972) by Edward Brecher and the editors of Consumer Reports) - They have serious negative effects on health, while the others do not? - For economic and political reasons? - we tried to prohibit alcohol but it didn't work, prevalence went down a little, crime was crazy

cannabis

- THC - marijuana: fired leaves and loses, smoked or pipe, baked in brownies, ingested - hashish: dried resin, smoked, eaten after being baked, - oral: slower, two-three times larger to have the same effect - short term effects - getting high: sense of well begin and happiness, effects on mood, feel happy but sometimes anxious, easily influenced by how others are feeling - temporal disintergration: people have trouble retaining and organizing information over relatively short periods of time, lapses in attention/concentration - long term effects: - tolerance effects in human is ambiguous, some people say people don't develop unless exposed to high doses, - more senstive after repeated use, refer tolerance - withdrawal not likely for low doses, high doses, irritability, restlessness, insomnia - certain type of performance deficit, in attention, learning, dissection making, cognitive decline

genetics of alcholism

- alcohol abuse tend to run in families - lifetime prevalence of alcoholism among parents, siblings and children of people with alcoholism is 3-5x higher than rate in general population - twin/adoption: concordance higher for MX twins - austratlia: concordance rates fo alcohol depdence 56% in male MZ, 33% in male DZ twins - corrsponding figures for MZ/DZ twin pairs were 30/17% - concodrance rates higher for men reflects higher prevalence rate for alcoholism among men - adoption study: - biological parent ALC, adopted by adoptive parents - influence of genetics on alcohol ue disorder - offspring of alcoholics (biological parents) more likely to development drinking problems, familial nature of alcoholism partially determined by genes - ADH and ALDH metalosim of alcohol, flushing genes for personality traits; novelty seeking, sensation seeking,

gambling disorder

- classification confusing, DSM-IV, impusle control disorder - DSM-5 moved to subtance related and addictive disorders, because they also have substance disorders often - symptoms shared with albolism, preoccupation, unable to quit - most gambling nota ssicated with mental disorder, recreation, pathological gambling: out of control, takes over life, horrendous financial personal problems - is pathological gambling an addiction? - most likely open door to other behavioral addiction - excessive internaet gaming, seuxal beahviro, shopping, exercise - substance use repeated exposure to tocix chemicals, ebahvioral addictions don't, tolerance/withdrwawl, not in gambling, - meaning of terms: compulsive gambling vs. gambling addiction, before was in impulse control disorder, vague, - compulsion: repedictive behaviors that reduce anxiety, impulsive: failure to resist temptation, - addiciton: relieve withdrawal - are beavhioral addictions related to these things? confusing - DSM-5 thought that gambling disorder activate reward pathways, important but neural reward pathways still not so clear - "Addiction" absence of responsibility for behavior, alhocl is central activity, set of interests and patterns that motivate identity, behavior, not addiction, - are you not responsible for shopping, exercising, sex, gambling? better philosophical question than DSM question

frequency

- drug related problems found in most countries - use of specific drugs determined by their availability - opium used in southeast asia and middle east - cocaine: south america/north america - cannabi, around the world, - japan amphetamine - culture shapes people's choice bout use of drugs, influence amount of drug that is typically ingested, route of administration, person's beliefs about drug effects - coca: relieves cold, hunger, thrust in religious ceremonies - not as severe as the refined drug - many people who use drug do not become dependent, - age of onset is important - rate for alcoholism for men who started before 14 is double than found among males who began drinking at age 18 - same pattern found among women, those who begin to use alcohol at an earlier age have a much higher risk of becoming addicted - most people who occasionally use alcohol illicit drugs do not become addicted, problems develop after extended exposure to a drug, 2-3 years after starting the drug is the symptoms

- course and outcome

- hard to say course, age of onset varies, stage between exposure and impaired control, social impairment, pharma symptoms, timing when the person moves through stages is different - period of heavy use alternate with abstinence - study Boston, Harvard, followed for 70 yard, 21% of college men and 35% of city core men met diagnostic criteria of alcohol abuse - morality rate was higher among men who abused alcohol than among those who did not, heart disease and cancer were twice ad common among the alcohol abuser, - alcoholic men went through repeated cycles of abstinence followed by relapse - mortality rate higher among men who abused alcohol than among those who didn't - heart disease and cancer were twice as common among the alcohol abusers, - alcholic men went through repeated cycles of abstinence, fallowed by relapse, life course of abstinence followed by relapse - abstinence defined as less than one drink per month - social dirnking refers to problem-free drinking for 10 years or more - controlled drinking is more than one drink per month for at least two years with no reported problem - core city men abusing lachol at an earlier age, more likely to achieve stable abstinence, average age of onset was 40 for college men and 29 for city - 20 years alternating between period of controlled drinking and alcohol abuse, proportion of men who continued to abuse alcohol went down after the age of 40 - proportion of alcoholic men in both groups who became completely abstinent went up slowly - longer the man remained abstinent, greater probability continued abstinent - relapse for alcohol abuse was unlikely among men who remain abstinent for at least six years - is there a safe point for risk of relapse? six year mark?

DRUG USE AND DEPENDENCE (NCS DATA)

- national comordbity survey: - % reporting lifetime dependence - highest prevalence is for tobacco (not surprising 20 years ago) - alcohol is 14% (more for men) - pot 4% - less prevalence of illegal drugs - % used (other than medical use) - 76% tobacco - 92% - dependent if used - 32% used tobacco products went on to be dependent - heroin: small percent lifetime dependence, small percent ever tried, 25% use of heroin beam dependent

*book tobacco

- natural source - high doses, bad effects, controlled doses easier by smoking - short term effects - increases in heart rate and blood pressure - CNS nicotine pervasive effects on nuerotnsmitter systems - release of norepinephrine, CNS arousal - release of dopa, norpeihrine, known as reward system of the brain, - serotoinin system influenced too, mimics antidepressant - effet on subject mood staes: "helps them relax" but it actually leads to more arousal, low doses of nicotine: increased arousal but higher leads to relaxation, or it takes away feelings of withdrawal - long term consequences - nicotine: most harmful/deadly addictive drugs - development of both tolerance and withdrawal symptoms among people who regularly smoke or chew tobacco - sleep problems, weight gain, concentration difficulties, mood swings, craving - increase risk for disease: heart disease, lung disease, ancer, fertility issues, birth defects

integrated systems

- nitial experimentation with drugs influenced by environment: family, peers, neighborhood - access to drugs - drinking alcohol short term positive effects, diminished self awareness, stress reducing, improved mood, determined by person's expectation - genetic factors: after using alcohol genetic factors more important in shaping patterns of use, interact with environment, genetic predisposition abnormal reaction to alcohol - dopamine acitivyt, definiciy in serotinin in limbic system - drinking correc toporblem increases serotonin and person feels worse after tolerance - person tolerant to effects of alcohol and must drink more - permancen neruological impaoriment

opiates

- opaites: drugs that have properties similar to opium, poppy, - morphine, codeine: medicine to relieve pain, prescription, - opoids: synthetic version of opium, used to reduce pain - heroin: synthetic opiate that is made by modigyin morphine molecule, - opium sometimes eated/smoked, orally, - heroin: injected, inhaled, smoked - short term effects: state of dreamlike euphoria, increased sensitive hearing/vision - rush: breig intense pleasure, orgasm - positive emotional effects of opiates do not last, replaced by long term negative changes in mood/emotion, relieved after 30-60 mins - neasua, ovimiting, decreases sex drive, felitiy - speedball: combo of cocain and opiates, - feelings after injecting heroin: - siren in his head, vomit but then heroin stops it, sweat, doesn't hurt, spotty work history, rent, - comatose, convulsions, emergency room - long term consequences: - high dose, people who are addicted chronically lethargic, lose motivation to ram in productive - low doses: remain healthy and work in spite of addiction - dependent on how easy it is to get opiates - addicte dto popiates: preoccupied with finding/using drug, rush and avoid withdrawal, tolerance quickly have to increase, expenses, die

- outcome results and general conclusions

- project MATCH: test value of matching clients to specific forms of treatment, outcomes related to personality traits? - CBT, 12 step program (AA), motivational enhancement therapy (4 sessions for 12 weeks ) - most people attended some AA, randomly assigned to conidtion - all three led to improvements in drinking/life - drank 6 days a month from 25, - not that difference in treatments, 12 step facilitation 24% abstinence, 15% in other groups - little reason to match people they all owrk - naturalistic evaluation of substance abuse treatment problems abminititered at 15 sites by VA - compared programs that emphasize d three aprorahced to treatment: 12 step, CBT, eclectic therapy: combo - not randomly assigned, - results similar to MATCh - patients in all three made improvements in substance use and osical/job function, - favor 12 step program - no individual differences - gneral thoughts - imporvmenet in reduce drug use likely to persist for months after treatment - one form is not more effective than others, people favor AA in achieving abstinence - no indivdiaul diffdrences in one treatment - increased treatment/self help helps - not just help with drug use but also social/occupational functioning - long term outcome: predicted by cling resources, social support, lack of stress, stressful ice: more likely to drink

amphetamine/cocaine

- psychomotor stimulants produce their effects by simulating the actions of certain neurotranmistters, specifically epinephrine, norpeniephiren, dopamine, srotonin, - cocaine is a natrualyl occurring drug that is extracted from a leave - amphetamines produced synthetically - simtulants: orally, inject, inhale, earier to maintsin constant blood level when taken orally, dramatic if sniffing, "Freebasing" lighting fire to cocaine - short term effects: stimulants because they activate the sympathetic nervous system, increase heart rate and blood pressure, dilate blood vessels and air passages - suppress appetite, prevent sleep, - reason for abuse - can also lead to dizziness, confusion, panic - induce positive mood state - low doses of ampeth: confidence, friendly energetic, high doses, euphoria, - cocaine: enhances sexual arousal, prolonged use leads to sexual dysfunction, tolerance develops, later are depressed - acute overdoses can result in irregular heartbeat, convulsions, coma, and death - long term conceseuences: can lead to psychosis, increase with reposted exposure, appear in people with no past history of mental disorders, - disruption of occuptiaonl/social roles - money - sell homes, crime, increase in violent behavior, drug induced increase in paranoia/hostility - people who discontinue taking stimulant drugs do not experience severe withdrawal symptoms, most common reaction is depression, suicidal thoughts

should tobacco be legal?

- restrict tobacco for young people, public spaces, - nictoine is addictive - people develop dependence 'didn't want to make illegal, not great, balk markets - prevention efforts: porhibt under 18, resrticts ads, - minimize risk of dependence

developmental framework

- stage model: refusing form outset - 1. under what circumstances does the person begin to use the subsnstace, important if they develop more severe problem down the road - risk factors for twins, age at which the person began to drink (outside of the family) - dirnking at 12, much bigger risk - cricumstances in drinking: cultural thing, families that allow the children to drink - if the initiation to alcohol is in a prosicaol context (like at shabbat) - initiaont occur in peers where purposeof drinking is to slam down shots and can't walk, not a good predictor, increasines probability you will get alcoholism - 2. regular user: under what circumstances do you continue using, for the rest of your life you are a casual user, middle ground, how regular is it?? - development of tolerance and withdrawal, why are some people at the end of the spectrum and others are not - IF YOU HAVE NEVER USED THE SUBSTANCE YOU CAN NEVER BECOME ADDICTED - if you become dry, then you drink again you will become an alcoholic (that's what Alcoholic Anonymous says, you can NEVER drink again) - extent to people who recover isn't recorded because it's anonymous - cannot go back to social drinking - study: many of the people followed in longitudinal study who had alcohol problems, became alcoholics, and stopped, but returned to social drinking - interesting commitments, but not scientifically proven theories - Initiation and continuation - Escalation and transition to abuse - Development of tolerance and withdrawal

other disorders with addictions

- substance use disorders often exhibit other forms of mental disorder as well - most common: antisocial PD< mood disorders, anxiety disorders - ASPD/alcoholism, general predisposition twoard beahvioral disinihibition - prolonged heavy drinking ruslts in feelings of anxieyt/derpession, - colohol: conflict with family, - sometimes use alsohocl to self medication

sedatives, hypnotics, anxiolytics

- traquilizer: drecrese anxiety or agitation - hypnotics: used to help people sleep - sedative: drugs that calm people or reduce excitment - barbiturates: phenobarbital, amorbarital, used for variety of purposes, treat anxiety - benzodiasepnies: diazepam, alprazolam Xanax, valium replaced barbiturates in treatment, because of lower probability of overdose - short term effects - can lead to intoxication that is like alcohol, impaired judgment,s low speech, lack of coordination, - pleasant, warm drowsy feeling like opiates, - benzodiaspeinse: increase ni holstile/agressive beahvior, rage reaction - long term effects: stop taking high doses of benzo, discontinuance syndrome: reutn of original anxiety if med was used for that, withdrawal: irritability, pranoia, sleep disturbance, agitation, mucle tension, restlessness, - cannabis

TREATMENT - PSYCHOLOGICAL

12 Step Recovery Program Alcoholics Anonymous, for example Studies show that this is effective CBT Heavy drinking viewed as learned maladaptive coping mechanism Identify antecedents and consequences of drinking Teach new coping skills

weed abuse/dependence

18% increase in the prevalence of cannabis use disorders amongst cannabis users in the last decade Cannabis use disorders are amongst the top unmet health needs worldwide Dependence Criteria Budney (2006) has shown that cannabis withdrawal is a clinically valid and reliable syndrome Characteristics include: anger, aggression, irritablilty, anxiety, restlessness, sleep problems, decreased appetite Added to DSM-5

DSM-5 DRUG USE DISORDERS

2/11: Tolerance Withdrawal Use of larger amounts or for longer than intended Persistent attempts to quit or cut back Give up important activities to drink Spend a lot of time drinking or getting alcohol Physical or mental health problems due to alcohol use Failure to fulfill major role obligations Recurrent use in hazardous situations Recurrent interpersonal or social problems due to use Craving - strong urge or desire to use drug (New criterion) - not EVERYONE HAS AN ALCOHOLIC IN THIER FAMILY, NOT JUST HAVING A DRINK EVERY NIGHT -severity rating: Mild: 2-3 symptoms Moderate: 4-5 symptoms Severe: 6-11 symptoms

PREVIOUS DEFINITION OF SUBSTANCE DEPENDENCE (in DSM-IV)

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: -Tolerance (need to take more of the drug, or markedly diminished effect with same amount) -Withdrawal (symptoms when you stop, or take the drug to avoid/relieve onset if withdrawal) **Note: Diagnostic differences in abuse/dependence have been removed from DSM-5

DRUGS OF ABUSE

Also called a psychoactive substance A chemical that alters a person's mood, level of perception, or brain functioning What is an addictive drug? A chemical that is self-administered and leads to (1) compulsive use, (2) tolerance, and / or (3) withdrawal

marijuana

Also called cannabis Psychoactive component is THC Absorbed through lungs ~10 minutes after inhalation Half-life of 3-5 days Interacts with cannabinoid receptors and modulates mood and though

THE FDA AND NICOTINE

An intermediate policy -Starts with the recognition that an outright ban would not be effective Attempts to prevent (or minimize) smoking among adolescents Sale to minors is illegal; taxes increased substantially Advertising is curtailed Education is enhanced

TREATMENT - BIOLOGICAL

Antabuse Causes vomiting upon ingestion of alcohol Naltrexone Opiate antagonist that reduces craving Tranquilizers to reduce withdrawal symptoms

prev weed

Cannabis is used in some form by 50-70% of population Lower in females Cannabis Abuse: Males: 4% Females: 1% Higher in 18-29 year olds Cannabis Dependence: Males: 2.5% Females: 1.2% Higher in 18-29 year olds Mean age of onset (use): 17 years

alcohol expectancies

Common: Alcohol transforms experiences in a positive way ("makes future seem brighter") Alcohol enhances social and physical pleasure ("nice way to celebrate") Alcohol enhances sexual performance Alcohol increases power and aggression Alcohol reduces tension Learned socially at a young age Predict future drinking behavior (adolescents with positive expectances drink more heavily in subsequent years) Positive expectancies seem more influential than negative expectancie

EXAMPLES OF DRUG ADDICTION

Darryl Strawberry Baseball player Rookie of the year with the New York in 1983 Voted to All-Star Team 8 times (1984-1991) Suspended from professional baseball 3 times in 5 years after screening positive for cocaine Jailed repeatedly between 2000-2004 Now lives in St. Charles Country, MO Robert Downey, Jr. Nominated for Academy Award for his role in "Chaplin" (1992) when 27 Played a cocaine addict in "Less Than Zero" (1987) Own drug problems began at an early age Served a 3-year prison term for drug possession (released in 2000) Now doing well Amy Winehouse 2008 Grammy's for record of the year, song of the year, and best female pop performance Problems with self-harm, depression, eating disorders, and substance dependence Heroin, ecstasy, cocaine, alcohol Died of alcohol poisoning, 2011 Age 27 (the 27 Club) Same as Hendrix, Joplin, Morrison

drug tolerance: opponent processing model

E.g., morphine relieves pain (reduces pain sensitivity) The CR is an increase in pain sensitivity Assume there is a "hard-wired" homeostatic process that suppresses some emotional and motivational states Anticipatory responses attenuate drug effects and contribute to tolerance For many drugs, the CR is an anticipatory compensation Drug-associated environmental cues elicit responses that are opposite to the effect of the drug The body essentially gets ready for the drug when in that environment

behavhioral effect weed

Euphoria and relaxation Enhanced sensory perception Distortion of time and loss of memory Increased sociability Wear off causes lethargy and increased appetite Cannabis intoxication can cause anxiety and paranoia

alcohol: social factors

Experimentation *Parent modeling of appropriate v. inappropriate use of alcohol How do parents influence children's drinking? By influence attitudes and expectations By providing access and monitoring use less closely By creating a negative emotional climate? Adolescents with alcoholic parents High levels of negative affect in the home Girls with opposite-sex friends Cultural variations in rates of alcoholism - people who don't drink won't get lacholism, religious reasons to drink, jews had a lower reates of alcoholism, cultural restraint decrease rates for alcohol used - development of addiction requires continued use, influence by manner in which drug is consumed, - initial experimentaiton: those who are rebellious, extraverted, parents model use parents can serve as models wfor using drugs, access to drugs - acloholisecne with alcoholic parents are more likely to drink - parental monitoring/discipline inpmct - level of neagiatve affect high in families of aochloic parents - unpleasant emotional climate - peer/sibling substance use robust predicts of adolescent alcohol and drug use, - impact of friends' alohcol use is greater among adolescent girls than boys

substance disorders used to be:

In the past, DSM-IV recognized two levels of problems with substance use: Dependence Abuse Substance Dependence is the more severe form of disorder Involves a pattern of compulsive use, tolerance, and withdrawal Substance Abuse was presumably a less severe form of disorder, in which drug use interferes with the person's ability to function "Harmful consequences" without evidence of tolerance, withdrawal, or compulsive use Note: Abuse and Dependence diagnostic differences have been taken out of the DSM-5

BIOLOGICAL FACTORS

Initial physiological reactions dramatically affect early drinking experiences Some people are unable to tolerate even small amounts of alcohol: skin flush Also nauseated and abnormal heartbeat perhaps 30-50% among people of Asian ancestry (lower rates of alcoholism) In males (but also shown in females): Neither parent alcohol dependent - risk: 12.4% 1 parent alcohol dependent - risk: 30% 2 parents alcohol dependent - risk: 42% Children of parents with alcohol use disorders adopted by non-alcoholics: twice as likely

expectations about the effects (psych)

Laboratory studies show that some effects of alcohol are due to what people think it will do to their behavior "Balanced Placebo Design" used to study these effects Shows expectancy effects for loss of control drinking, aggression, sexual arousal, and so on book: - expectation account for many effects that assumed to be products of drug - thought they drink alcohol but water, exaggeration aggression, asexual arousal - why drink? - positive experiences - enhace social/ogysical pleasure - enahnces sexual perofrmance - increases power/aggresion - social assertiveness - reduce tension - if they have positive expectatios of alcohol go on to consume more of it - expecations form person expericences, environmental: parents/peers, - studies of people at reisk for disorders - risk: probability outcome will occur - risk for alcohol 14/100 - 8/100 for all durgs - risk factors: variables that are addociated with higher probability of developing a disorder, not causality, correlation - dmeographics, gender, biological/psychological, history of psychopathology, expectancies, - longitnudal studies for risk factors: expensive, large number, hard to find data of drug abusers because it is such a small group - special methods to increase productivity of longitudal research:high risk reasrch design: subjects selected from general population beaded on risk factor, positive family history, pschyholgoical thing demographic, identify factors that increase or decrease probability that people who are vulnerable to a disorder wille veutnatlly develop symptoms

alcohol

NOT: - Alcohol use - Casual drinking - Glass of wine/few beers every day - Heavy drinking/binge drinking (without symptoms) - Getting drunk - BUT excessive/binge drinking and repeatedly getting drunk are hallmarks for developing alcoholism - lifetime prevalence - 50% of individuals 18 or over are regular drinkers - Lifetime Prevalence: Alcohol use disorder: 29.1% - 20% receive treatment - Alcohol Abuse -18% - Alcohol Dependence - 12% - 24% with dependence receive treatment, small percentage receive treatment - 23.3% of people 12 or older have a history of binge-drinking - 12.4% of people 12 or older have driven under influence over the past year - demographics - Men to women -2:1 - Age: severity highest in younger people, lowest in the elderly - Ethnicity (highest to lowest prevalence) - Native American, White, Black, Hispanic, Asian - Marital Status: never married/widowed greater than married - IGNORE Education: College > high school - Income: lower income > higher income for severe problems (no difference at low/moderate levels) - Urban > rural - Region (most to least prevalent): West, Midwest, Northeast, South

STUDY OF HEROIN OVERDOSE DEATHS

Overdose deaths in humans are mysterious May result, in part, from a failure of tolerance Rats injected with heroin 15 times (every other day) Day 1: 1mg/kg; Days 2-3: 2mg/kg Eventually: building up to 8 mg/kg (days 8-15) Control rats received 30 daily injections of dextrose All rats received one 15mg/kg dose at the end Similar tested rats (received final high does in context of same cues that signaled lower doses) Differently tested rats (received final high dose in context of cues not previously associated with drug) ????

drug tolerance: conditioning view

Psychological factors are involved in the development and maintenance of tolerance Tolerance is, in part environment specific Hinges on classical conditioning

ALCOHOL WITHDRAWAL DELIRIUM

Sometimes happens to those that drink extensively for a long time Usually occurs following a prolonged drinking spree (very rarely) Disorientation to time and place (ex: mistakes hospital for jail) Vivid hallucinations (often of small fast moving animals) Acute fear - often of hallucinations Extreme suggestibility (see almost any animal if suggested) Physiological symptoms - perspiration, fever, etc. Lasts 3-6 days followed by extreme sleep Death rate ~10% due to physiological symptoms

substance use etiology

Think in terms of integrated systems 1 in 10 drinkers will develop serious problems Biological factors are obviously involved (only certain kinds of drugs are addicting) Social factors are also involved (why do people drink or use drugs in the first place?) Developmental framework (sequences of stages) Initiation and continuation Escalation and transition to abuse Development of tolerance and withdrawal

TOLERANCE AND WITHDRAWAL the so-called physiological symptoms of addiction

Tolerance The nervous system becomes less sensitive to the effects of substance Person needs larger quantities of the drug to achieve the same effects Potential Reasons: Metabolic reasons (liver breaks down drug more efficiently) Pharmacological reasons (synaptic down-regulation) Behavioral reasons (classical conditioning) -Withdrawal Symptoms experienced when a person stops using a drug

TENSION REDUCTION HYPOTHESIS (psychological)

Traditional behavioral view of alcoholism focused on immediate subjective effects of alcohol (presumably to reduce tension) Lab studies showed variable effects Attention allocation model helps explain inconsistencies (alcohol myopia - or "short-sighted information processing") "Drunken Excess" will occur when strong cues pull for a response and the response is usually inhibited by higher level cognitive processes

alcohol: treatment

Treatment is difficult Disease of very much denial Often need to hit rock bottom before seeking treatment Biological Medications to block desire Reduce withdrawal side effects Psychological Group therapy Environmental intervention CBT

BIOLOGICAL FACTORS: TWIN STUDIES

When the proband is an alcoholic in treatment (Heath and Martin, 1997) Males: MZ=56% DZ=33% Females: MZ=30% DZ=17% Higher concordance rates in male twins reflect higher rates of alcoholism among men Heritability analysis suggest that two thirds of variance is due to genetic factors for both men and women

PSYCHOLOGICAL FACTORS

Who is at risk: Increased stress reduction following consumption Larger conditioned responses to alcohol cues Expectations - more positive Self-medication for anxiety and/or stress Tension reduction hypothesis Expectancies Behavioral tolerance