disorders c 11 perspectives treatment -r prev use v types...

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CHAPTER 11

SUBSTANCE-RELATED

DISORDERS AND

IMPULSE CONTROL

DISORDERS(PP. 392-437)

1 Substance-Related & Impulse Control

Disorders

Perspectives

Abuse v Dependence

Use v Intoxication

Hallucinogens

Stimulants

AnxiolyticSedative

Hypnotic

Alcohol

Bio

Depressants Opioids

Types

Causes

Prev

Tolerance & Withdrawal

Other

HR

Caffeine

Cocaine

Nicotine

Amphetamines

Designer

Cannabis LSD

Other

Steroids

Inhalants

Socio-Cultural

Psych

Bio

Treatment

PsySoc

Integrated

Impulse Control Disorders

2Last

• Nature of Substance-

Related Disorders

– Problems related to use and

abuse of psychoactive

substances

– Many physiological,

psychological, and

behavioural effects

• Some Terms and

Distinctions

– Substance Use vs. Substance

Intoxication (right)

– Substance Abuse (+1) vs.

Substance Dependence (+2)

– Tolerance vs. Withdrawal

(+2)

PERSPECTIVES ON

SUBSTANCE-RELATED

DISORDERS: AN

OVERVIEW (PP. 393-400)

3 4

5

• Addiction pervasive

– Many Substances AND other Activities Addictive (+1)

– Substances of abuse vary in Addictiveness (+2)

• Five Main Categories of Substances

– Depressants: result in behavioural sedation (e.g., alcohol,

sedative, anxiolytic drugs)

– Stimulants: increase alertness and elevate mood (e.g., cocaine,

nicotine, caffeine)

– Opiates: primarily produce analgesia and euphoria (e.g., heroin,

morphine, codeine)

– Hallucinogens: alter sensory perception (e.g., marijuana, LSD)

– Other: include inhalants, anabolic steroids, medications

PERSPECTIVES ON SUBSTANCE-RELATED

DISORDERS: AN OVERVIEW (PP. 399-400)

6

2

PERSPECTIVES ON

SUBSTANCE-

RELATED

DISORDERS: AN

OVERVIEW (P. 397)

7

PERSPECTIVES ON SUBSTANCE-

RELATED DISORDERS:

AN OVERVIEW (P. 398)

8Map

DEPRESSANTS

• Alcohol Use Disorders

• Sedative, Hypnotic, or

Anxiolytic Substance

Abuse Disorders

– Barbiturates

– Benzodiazepines

9

Alcohol Consumption

• Psychological and Physiological

Effects of Alcohol

– Central Nervous system depressant

– Influences several

neurotransmitter systems, but

mainly GABA

• Effects of Chronic Alcohol Use

– Alcohol intoxication (+1)

– Alcohol withdrawal

– Associated brain conditions (right):

Dementia, Wernicke’s disease

– Liver Disease (+2)

– Fetal alcohol syndrome (+3 +4)

• DSM-IV Criteria for Disordered

Alcohol Use

ALCOHOL USE

DISORDERS (PP. 400-402)

10

11

THE DEPRESSANTS: ALCOHOL USE DISORDERS (P. 400)

12

3

FETAL

ALCOHOL

SYNDROME

13 FETAL ALCOHOL SYNDROME14

• In Canada:

– Most adults drink in moderation

– 20 percent of Ontario population moderate to high risk for alcohol

dependence (Adalf, Ivis, and Smart, 1994)

– about 23% of Canadians exceed low-risk guidelines for alcohol

consumption and about 17 percent classified as high risk drinkers

(Canadian Centre for Substance Abuse [CCSA])

– Men more likely than women to drink and are also more likely to

drink heavily (Statistics Canada, 2003): percent 2 or more drinks

daily (Canada, 2004, graph)

– International Statistics (+1)

ALCOHOL: SOME FACTS AND STATISTICS (PP. 402-405)15 16

• Facts and Statistics on Problem Drinking

– 10% of Americans experience problems with alcohol

– Most persons with alcoholism can moderate or cease drinking on

occasion

– 20% of those with alcohol problems experience spontaneous

recovery

– Anhedonia: Lack of pleasure, or indifference to pleasurable

activities

– Affective flattening: Show little expressed emotion, but may still

feel emotion

• Changes in consumption

– Reduced consumption in many countries, but not all (+1)

ALCOHOL: SOME FACTS AND STATISTICS (PP. 402-405)17 18

4

• The Nature of Drugs in This Class

– Sedatives: calming

– Hypnotic: sleep inducing (e.g., barbiturates)

– Anxiolytic: anxiety reducing (e.g., benzodiazepines)

• Effects similar to large doses of alcohol

– Combining such drugs with alcohol is synergistic

• All exert their influence via GABA Neurotransmitter System

• DSM-IV criteria for sedative, hypnotic, or Anxiolytic

substance use disorders (+1 +2)

SEDATIVE, HYPNOTIC, OR ANXIOLYTIC

SUBSTANCE USE DISORDERS: AN OVERVIEW(PP. 405-406)

19 20DSM-IV-TR CRITERIA FOR SEDATIVE, HYPNOTIC, OR

ANXIOLYTIC INTOXICATION

• A. Recent use of a sedative, hypnotic, or anxiolytic.

• B. Clinically significant maladaptive behavioural or psychological changes (e.g., inappropriate sexual or aggressive behaviour, mood lability, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, sedative, hypnotic, or anxiolytic use.

• C. One (or more) of following signs, developing during, or shortly after, sedative, hypnotic, or anxiolytic use:

– slurred speech

– incoordination

– unsteady gait

– nystagmus

– impairment in attention or memory

– stupor or coma

• D. Symptoms not due to general medical condition and not better accounted for by another mental disorder.

21DSM-IV-TR CRITERIA FOR SEDATIVE, HYPNOTIC OR

ANXIOLYTIC WITHDRAWAL

• A. Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been heavy and prolonged.

• B. Two (or more) of following, developing within several hours to a few days after Criterion A: – autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)

– increased hand tremor

– Insomnia

– nausea or vomiting

– transient visual, tactile, or auditory hallucinations or illusions

– psychomotor agitation

– anxiety

– grand mal seizures

• C. Symptoms in B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.


• Specify if: With Perceptual Disturbances

Map

• Nature of Stimulants

– Most widely consumed drug in

Canada and United States

– Such drugs increase alertness and

increase energy

– Examples include

• Amphetamines

• Cocaine

• Nicotine

• Caffeine

STIMULANTS: AN OVERVIEW (P. 406)22

• Effects of Amphetamines– Produce elation, vigor, reduce fatigue

– Enhance the release of dopamine and norepinephrine, while blocking

reuptake

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

• DSM-IV Criteria for Amphetamine Intoxication (+1)– Psychological and Physiological symptoms

• DSM-IV Criteria for Amphetamine Withdrawal (+2)– Psychological and Physiological symptoms

• Ecstasy and Ice– Effects similar to speed, but without the crash

– Recreational use of Ecstasy rose sharply in late 1980s

– Among Toronto students surveyed in 1999, past-year use of Ecstasy was 7%,

the highest rate observed in gradual upward trend since 1991

– Both drugs can result in dependence

STIMULANTS: AMPHETAMINE USE DISORDERS (P.

407)

23 24DSM-IV-TR CRITERIA FOR AMPHETAMINE

INTOXICATION

• A. Recent use of amphetamine or related substance (e.g., methylphenidate).

• B. Clinically significant maladaptive behavioural or psychological changes (e.g., euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviours; impaired judgment; or impaired social or occupational functioning) that developed during, or shortly after, use of amphetamine or a related substance.

• C. Two (or more) of following, developing during, or shortly after, use of amphetamine or related substance:

– tachycardia or bradycardia

– pupillary dilation

– elevated or lowered blood pressure

– perspiration or chills


– evidence of weight loss

– psychomotor agitation or retardation

– muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias

– confusion, seizures, dyskinesias, dystonias, or coma


• Specify if: With Perceptual Disturbances

5

25DSM-IV-TR CRITERIA FOR AMPHETAMINE

WITHDRAWAL

• A. Cessation of (or reduction in) amphetamine (or related substance) use that has been heavy and prolonged.

• B. Dysphoric mood and two (or more) of following physiological changes, developing within few hours to several days after Criterion A

– Fatigue

– Vivid, unpleasant dreams

– Insomnia or Hypersomnia

– Increased appetite

– Psychomotor retardation or agitation



• Effects of Cocaine

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

– Effects result from blocking the reuptake of dopamine (+1)

– Cocaine is highly addictive, but addiction develops slowly

– Cocaine use in Canada has declined over the last decade

• DSM-IV Criteria for Cocaine Intoxication (+2) and

Withdrawal

– Psychological symptoms

– Physiological symptoms

– Most cocaine users cycle through patterns of tolerance and

withdrawal

STIMULANTS: COCAINE USE DISORDERS (PP. 407-409)26

COCAINE BLOCKS DOPAMINE REUPTAKE 27 28

• Effects of Nicotine

– Stimulates Central Nervous System, specifically nicotinic

acetylcholine receptors

– Results in sensations of relaxation, wellness, pleasure

– Nicotine highly addictive; relapse rates high (+1)

• DSM-IV Criteria for Nicotine Withdrawal Only

– Psychological and Physiological symptoms

– Nicotine users dose themselves to maintain steady state of

nicotine

• & Psychological

Disorders

NICOTINE USE DISORDERS (PP. 409-410) 29

STIMULANTS:

NICOTINE USE

DISORDERS (P. 410)

30

6

• Effects of Caffeine – The

“Gentle” Stimulant

– Found in tea, coffee, cola drinks,

and cocoa products

– Caffeine blocks reuptake of

neurotransmitter adenosine

– Small doses elevate mood and

reduce fatigue

– Used by over 90% of Americans

– Regular use can result in tolerance

and dependence (+1)

• DSM-IV Criteria for Caffeine

Intoxication

– Psychological and Physiological

symptoms (+2)

CAFFEINE USE


31 32• Caffeine mildly addictive, as indicated by Withdrawal

Symptoms, even when moderate amounts of caffeine are

withdrawn for 18 to 24 hours

– Symptoms include: Headache, Fatigue, Irritability, Depression, and

Poor Concentration

– Symptoms peak within 24 to 48 hours and progressively decrease

over course of a week

– To minimize withdrawal symptoms, experts recommend reducing

caffeine intake gradually

33

Map

• The Nature of Opiates and Opioids– Opiate: natural chemical in opium poppy

with narcotic effects (i.e., pain relief)

– Opiods: class of natural and synthetic

substances with narcotic effects

– Often referred to as analgesics

– e.g., heroin, opium, codeine, morphine

• Effects of Opioids– Activate body’s enkephalins and

endorphins

– Low doses induce euphoria, drowsiness,

and slowed breathing

– High doses can result in death

– High mortality due to various causes:

homicide, suicide, overdose, HIV (+1)

• DSM: Intoxication & Withdrawal (+2 +3)

– Withdrawal can be lasting and severe

OPIOIDS(PP. 411-412)

34

35IDUs % HIV Cases 36

7

37DSM-IV-TR CRITERIA FOR OPIOD WITHDRAWAL

• A. Either of following: – cessation of (or reduction in) opioid use that has been heavy and prolonged (several

weeks or longer)

– administration of opioid antagonist after period of opioid use

• B. Three (or more) of following, developing within minutes to several days after A: – dysphoric mood


– muscle aches

– lacrimation or rhinorrhea

– pupillary dilation, piloerection, or sweating

– diarrhea

– yawning

– fever

– Insomnia



Map • Nature of Hallucinogens– Substances that change way user perceives

world

– May produce delusions, paranoia,

hallucinations, and altered sensory perception

– e.g., Marijuana, LSD

• Marijuana– Active chemical is tetrahydrocannabinol (THC)

– May produce several symptoms: e.g., mood

swings, paranoia, hallucinations (+1)

– Impairment in motivation is not uncommon: i.e.,

amotivational syndrome

– Major signs of withdrawal and dependence do

not typically occur

– Perhaps some link with heavy use and

schizophrenia (+2)

HALLUCINOGENS (PP. 412-415) 38

39 CANNABIS & SCHIZOPHRENIA40

• LSD and Other Hallucinogens

– LSD is most common form of

hallucinogenic drug

– Tolerance tends to be rapid, and

withdrawal symptoms are

uncommon

– Psychotic delusional and

hallucinatory symptoms can be

problematic

• DSM-IV Criteria for

Hallucinogen Intoxication

– Similar psychological and

physiological symptoms to

Marijuana

HALLUCINOGENS (PP. 412-415) 41

Map

42OTHER DRUGS OF ABUSE

• Other Drugs

– Do not fit into

previous classes

– Cause physical damage

to users

– Examples include:

• Inhalants

• Steroids

• Designer Drugs

8

OTHER DRUGS OF ABUSE: INHALANTS(PP. 415-416)

• Nature of Inhalants

– Substances found in volatile

solvents breathed into lungs

directly

– e.g.,: spray paint, hair spray,

paint thinner, gasoline,

nitrous oxide

– Rapidly absorbed with

effects similar to alcohol

intoxication

– Tolerance and prolonged

symptoms of withdrawal are

common

– DSM-IV criteria for inhalant

intoxication(+1)

• Statistics

– MB 2007 drug survey: 55

schools, 4,992 students; in

past year, 3.7% from grades 7

to senior 4 had used inhalants

– 2009 Ontario Drug Use Survey:

5.3% of students from grades

7 to 12 had used solvents.

– 2008 USA study: 8.9% of grade

8 students, 5.9% of grade 10

students and 3.8% of grade 12

students had abused inhalants

at least once in past year.

– Serious problem in isolated

communities (e.g., reserves) in

Canada (+2)

43 44DSM-IV-TR CRITERIA FOR INHALANT INTOXICATION

• A. Recent intentional use or short-term, high-dose exposure to volatile inhalants (excluding anesthetic gases and short-acting vasodilators).

• B. Clinically significant maladaptive behavioural or psychological changes (e.g., belligerence, assaultiveness, apathy, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, use of or exposure to volatile inhalants.

• C. Two (or more) of following signs, developing during, or shortly after, inhalant use or exposure:

– dizziness

– nystagmus

– incoordination

– slurred speech

– unsteady gait

– lethargy

– depressed reflexes

– psychomotor retardation

– tremor

– generalized muscle weakness

– blurred vision or diplopia

– stupor or coma

– euphoria


45• CBC program on children sniffing

gasoline in Innu community of

Shesatshiu, Newfoundland and

Labrador

– Sniffing produces highs similar to

alcohol

– Children report stealing

snowmobiles to sniff gasoline,

staying out sniffing rather than

going home, …

– One boy burned to death when gas

caught fire

– Children report suicidal thoughts

• Nature of Anabolic-Androgenic

Steroids

– Steroids are derived or synthesized

from testosterone

– Used medicinally or to increase

body mass

– Users may engage in cycling or

stacking

– Steroids do not produce a high

– Steroids can result in long-term

mood disturbances and physical

problems

– Major problem in competitive sports

OTHER DRUGS OF ABUSE:

ANABOLIC STEROIDS (P. 416)

46

• Designer Drugs

– Drugs produced by

pharmaceutical companies

for diseases

– Ecstasy, MDEA (“eve”),

BDMPEA (“nexus”), ketamine

(“special K”) are examples

– Heighten auditory and visual

perception, sense of

taste/touch

– Popular in nightclubs, raves,

or large social gatherings

– All designer drugs can

produce tolerance and

dependence; some judged to

be harmful (left graph)

OTHER DRUGS OF ABUSE:

DESIGNER DRUGS (P. 416)

47

Map

• Family, Twin, and Adoption Studies

– Substance abuse has a genetic component

• Heritability higher for higher levels of abuse (+1 +2): MZ > DZ

for Dependence, MZ = DZ for Use

– Much of focus has been on alcoholism

• Results clear for Males (+3), less so for females (+4)

• Heritability (h2): .38 to .70 for Males, .00 to .64 for Females

• Genetic differences in alcohol metabolism

– Multiple genes involved in substance abuse

• Perhaps biological differences across cultures?

– E.g., ALDH2 deficiency in 50% Asians leads to “flushing” and

other effects after alcohol consumption

CAUSES OF SUBSTANCE-RELATED DISORDERS:

FAMILY AND GENETIC INFLUENCES (PP. 416-417)

48

9

49 50

51

TWIN STUDIES ALCOHOLISM: MALES51

52

TWIN STUDIES ALCOHOLISM: FEMALES52

• Results of Neurobiological Research

– Drugs affect pleasure or reward centers in brain

– The pleasure center: dopamine, midbrain, frontal cortex

– GABA turns off reward-pleasure system

– Neurotransmitters responsible for anxiety/negative affect may be

inhibited


NEUROBIOLOGICAL INFLUENCES (PP. 417-418)

53

• Role of Positive and Negative Reinforcement

– Self-medication and tension reduction hypotheses

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

• Opponent-Process Theory (+1)

– Positive reactions to drug countered by Negative reaction to

restore neutral state. Negative reaction strengthens (hence

tolerance) and dominates when drug absent (hence withdrawal)

– Explains why crash after drug use fails to stop use

• Role of Expectancy Effects

– Expectancies influence drug use and relapse

• Alcohol myopia

– Shortsighted focus on superficial, immediate aspects of

experience; take health risks (e.g., unprotected sex)


PSYCHOLOGICAL DIMENSIONS (PP. 418-419)

54

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OPPONENT-PROCESS THEORY55 56CAUSES: SOCIAL & CULTURAL DIMENSIONS

PP 420-422

• Cultural Norms

– Influence use and manifestation of substance abuse

• e.g., Koreans expect to drink heavily on some social occasions

– Exposure to drugs varies across culture: e.g., smoking, alcohol

consumption, ..

• Exposure to Drugs is a Prerequisite for Use of Drugs

– Media, family, peers

– Parents and family appear critical

• Societal Views About Drug Abuse

– Sign of moral weakness: drug abuse is failure of self-control

– Sign of disease: drug abuse caused by some underlying process

• Statistics on Use and Abuse

– Abuse varies across nations and by ethnicity (+1)

EXCESSIVE ALCOHOL USE57

• Integrated Model (+1)

– Exposure or access to drug is necessary, but not sufficient

– Use depends on social and cultural expectations

– Used for pleasurable effects

– Abused for reasons that are more complex

• The premise of equifinality

• Stress may interact with psychological, genetic, social, and

learning factors

AN INTEGRATIVE MODEL OF SUBSTANCE-RELATED

DISORDERS (P. 422)

58

AN INTEGRATIVE MODEL OF SUBSTANCE-

RELATED DISORDERS (P. 422)

59

Map

• Biological Treatments

• Psychosocial Treatments

TREATMENT FOR SUBSTANCE ABUSE DISORDERS60

11

• Agonist Substitution

– Safe drug with similar chemical composition as abused drug

– e.g., methadone for heroin addiction, and nicotine gum or patch

• Antagonistic Treatment

– Drugs that block or counteract positive effects of substances

– e.g., naltrexone for opiate and alcohol problems

• Aversive Treatment

– Drugs that make injection of abused substances unpleasant

– e.g., antabuse for alcoholism, silver nitrate for nicotine addiction

• Efficacy

– Such treatments generally not effective when used alone

BIOLOGICAL TREATMENT OF SUBSTANCE-RELATED


61

• Debate over controlled use vs. complete abstinence as

treatment goals

• Inpatient vs. Outpatient Care

– Data suggest little difference in terms of overall effectiveness

• Community Support Programs

– Alcoholics Anonymous and related groups

– Seem helpful and are strongly encouraged

– But difficulty evaluating efficacy (effectiveness): anonymity, high

drop out rates, …

– Some principles contrary to psychological principles: e.g., giving

over control to “higher power” vs. taking responsibility (+1)

PSYCHOSOCIAL TREATMENT OF SUBSTANCE-

RELATED DISORDERS (PP. 425-428)

62

63

• Components of Comprehensive Treatment and Prevention

Programs

– Individual and group therapy

– Aversion therapy and covert sensitization

– Contingency management

– Community reinforcement

– Treatment matching (+1)

– Relapse prevention

• Harm reduction

– Reduce negative consequences

– e.g., Safe Injection Sites

• Prevention efforts through education

PSYCHOSOCIAL TREATMENT OF

SUBSTANCE-RELATED DISORDERS (PP. 425-429)

64

65

• Conrod et al

(2000)

• Matched or

not on

motivation /

personality

• Anxiety

Sensitivity

• Hopelessness

• Impulsivity

• Sensation

Seeking

Map

• Many substance abuse disorders start with irresistible impulse

• DSM-IV-TR includes five additional impulse-control disorders:

“impulse-control disorders not elsewhere classified”– Intermittent Explosive Disorder: act on aggressive impulses that result in

serious assaults or destruction of property.

– Kleptomania: recurrent failure to resist urges to steal things that are not

needed for personal use or their monetary value.

– Pyromania: irresistible urge to set fires.

– Pathological Gambling: cannot control impulse to gamble

– Trichotillomania: irresistible urge to pull out own hair from anywhere on

body, including scalp, eyebrows, and arms.

IMPULSE-CONTROL DISORDERS (PP. 429-431) 66

12

67Map

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

Classes– Depressants, Stimulants, Opiates, and Hallucinogens (+1)

– Specific diagnoses include dependence, abuse, intoxication, and

withdrawal

• Most psychotropic drugs activate dopaminergic pleasure pathway

in brain

• Psychosocial factors interact with biological influences to produce

substance disorders (+2)

• Treatment of Substance Dependence largely unsuccessful – Highly motivated persons do best when part of combined treatment

programs (+3)

• Substance-related disorders are 100% preventable

• Other Impulse Control Disorders (+4)

SUMMARY OF SUBSTANCE-RELATED DISORDERS (P.

434)

68

69 70

71 72

Map

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