Substance-Related Disorders

Perspectives on Substance-Related Disorders

• The Nature of Substance-Related Disorders

– Problems related to the use and abuse of psychoactive substances

– Produce wide-ranging physiological, psychological, and behavioral effects

• Some Important Terms and Distinctions

– Substance use vs. substance intoxication

– Substance abuse vs. substance dependence

– Tolerance vs. withdrawal

Perspectives on Substance-Related Disorders (cont.)

• Five Main Categories of Substances

– Depressants – Result in behavioral sedation (e.g., alcohol, sedative, anxiolytic drugs)

– Stimulants – Increase alertness and elevate mood (e.g., cocaine, nicotine, caffeine)

– Opiates – Primarily produce analgesia and euphoria (e.g., heroin, morphine, codeine)

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

– Other drugs of abuse – Include inhalants, anabolic steroids, medications

Figure 10.1

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

Figure 10.2

Easy to get hooked on, hard to get off

The Depressants: Alcohol Use Disorders

• Psychological and Physiological Effects of Alcohol

– Central Nervous system depressant

– Influences several neurotransmitter systems, but mainly GABA

• Effects of Chronic Alcohol Use

– Alcohol intoxication

– Alcohol withdrawal

– Associated brain conditions – Demenita and Wernicke’s disease

– Fetal alcohol syndrome

• DSM-IV Criteria for Disordered Alcohol Use

Figure 10.3

The path traveled by alcohol throughout the body

Alcohol: Some Facts and Statistics

• In the United States

– Most adults consider themselves light drinkers or abstainers

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

– Alcohol use is highest among Caucasian Americans

– Males use and abuse alcohol more so than females

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

• Statistics on Abuse and Dependence

– 10% of Americans experience problems with alcohol

– Most persons with alcoholism can moderate or cease drinking

– 20% of those with alcohol problems experience spontaneous recovery

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

• The Nature of Drugs in This Class

– Sedatives – Calming

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

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

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

– Combining such drugs with alcohol is synergistic

• All Exert Their Influence Via the GABA Neurotransmitter System

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

Stimulants: An Overview

• Nature of Stimulants

– Most widely consumed drug in the United States

– Such drugs increase alertness and increase energy

– Examples include amphetamines, cocaine, nicotine, and caffeine

Stimulants: Amphetamine Use Disorders

• Effects of Amphetamines

– Produce elation, vigor, reduce fatigue

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

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

• DSM-IV Criteria for Amphetamine Intoxication

– Psychological symptoms

– Physiological symptoms

• Ecstasy and Ice

– Produces effects similar to speed, but without the crash

– 2% of college students report using Ecstasy

– Both drugs can result in dependence

Stimulants: Cocaine Use Disorders

• DSM-IV Criteria for Cocaine Intoxication and Withdrawal

– Psychological symptoms

– Physiological symptoms

– Most cocaine users cycle through patterns of tolerance and withdrawal

• Effects of Cocaine

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

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

– Effects result from blocking the reuptake of dopamine

– Cocaine is highly addictive, but addiction develops slowly

Stimulants: Nicotine Use Disorders

• Effects of Nicotine

– Stimulates the central nervous system, specifically nicotinic acetylcholine receptors

– Results in sensations of relaxation, wellness, pleasure

– Nicotine is highly addictive

• DSM-IV Criteria for Nicotine Withdrawal Only

– Psychological symptoms

– Physiological symptoms

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

Figure 10.6

Relapse rates for nicotine compared to alcohol and heroin

Stimulants: Caffeine Use Disorders

• Effects of Caffeine – The “Gentle” Stimulant

– Used by over 90% of Americans

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

– Small doses elevate mood and reduce fatigue

– Regular use can result in tolerance and dependence

– Caffeine blocks the reuptake of the neurotransmitter adenosine

• DSM-IV Criteria for Caffeine Intoxication

– Psychological symptoms

– Physiological symptoms

Opiods: An Overview

• The Nature of Opiates and Opiods

– Opiate – Natural chemical in the opium poppy with narcotic effects (i.e., pain relief)

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

– Such drugs are often referred to as analgesics

– Examples include heroin, opium, codeine, and morphine

• Effects of Opiods

– Low doses induce euphoria, drowsiness, and slowed breathing

– High doses can result in death

– Withdrawal symptoms can be lasting and severe

– Activate body’s enkephalins and endorphins

• DSM-IV Criteria for Opiod Intoxication and Withdrawal

– Psychological symptoms

– Physiological symptoms

– Mortality rates are high for opiod addicts

Hallucinogens: An Overview

• Nature of Hallucinogens

– Substances that change the way the user perceives the world

– May produce delusions, paranoia, hallucinations, and altered sensory perception

– Examples include marijuana, LSD

• Marijuana

– Active chemical is tetrahydrocannabinol (THC)

– May produce several systems (e.g., mood swings, paranoia, hallucinations)

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

– Major signs of withdrawal and dependence do not typically occur

Hallucinogens: An Overview (cont.)

• LSD and Other Hallucinogens

– LSD is most common form of hallucinogenic drug

– Tolerance tends to be rapid, and withdrawal symptoms are uncommon

– Psychotic delusional and hallucinatory symptoms can be problematic

• DSM-IV Criteria for Marijuana and Hallucinogen Intoxication

– Psychological and physiological symptoms are similar

Other Drugs of Abuse: Inhalants

• Nature of Inhalants

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

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

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

– Tolerance and prolonged symptoms of withdrawal are common

– DSM-IV criteria for inhalant intoxication

Other Drugs of Abuse: Anabolic Steroids

• Nature of Anabolic-Androgenic Steroids

– Steroids are derived or synthesized from testosterone

– Used medicinally or to increase body mass

– Users may engage in cycling or stacking

– Steroids do not produce a high

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

Other Drugs of Abuse: Designer Drugs

• Designer Drugs

– Drugs produced by pharmaceutical companies for diseases

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

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

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

– All designer drugs can produce tolerance and dependence

Causes of Substance-Related Disorders: Family and Genetic Influences

• Results of Family, Twin, and Adoption Studies

– Substance abuse has a genetic component

– Much of the focus has been on alcoholism

– Genetic differences in alcohol metabolism

– Multiple genes are involved in substance abuse

Causes of Substance-Related Disorders: Neurobiological Influences

• Results of Neurobiological Research

– Drugs affect the pleasure or reward centers in the brain

– The pleasure center – Dopamine, midbrain, frontal cortex

– GABA turns off reward-pleasure system

– Neurotransmitters responsible for anxiety/negative affect may be inhibited

Causes of Substance-Related Disorders: Psychological Dimensions

• Role of Positive and Negative Reinforcement

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

– The self-medication and the tension reduction hypotheses

• Opponent-Process Theory

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

• Role of Expectancy Effects

– Expectancies influence drug use and relapse

Causes of Substance-Related Disorders: Social and Cultural Dimensions

• Exposure to Drugs in a Prerequisite for Use of Drugs

– Media, family, peers

– Parents and the family appear critical

• Societal Views About Drug Abuse

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

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

• The Role of Cultural Factors

– Influence the manifestation of substance abuse

An Integrative Model of Substance-Related Disorders

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

• Drug Use Depends on Social and Cultural Expectations

• Drugs Are Used Because of Their Pleasurable Effects

• Drugs Are Abused for Reasons That Are More Complex

– The premise of equifinality

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

Figure 10.7

An integrative model of substance related disorders

Biological Treatment of Substance-Related Disorders

• Agonist Substitution

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

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

• Antagonistic Treatment

– Drugs that block or counteract the positive effects of substances

– Examples include naltrexone for opiate and alcohol problems

• Aversive Treatment

– Drugs that make the injection of abused substances extremely unpleasant

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

• Efficacy of Biological Treatment

– Such treatments are not generally not effective when used alone

Psychosocial Treatment of Substance-Related Disorders

• Inpatient vs. Outpatient Care

– Data suggest little difference in terms of overall effectiveness

• Community Support Programs

– Alcoholics Anonymous and related groups

– Seem helpful and are strongly encouraged

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

Psychosocial Treatment of Substance-Related Disorders

• Components of Comprehensive Treatment and Prevention Programs

– Individual and group therapy

– Aversion therapy and convert sensitization

– Contingency management

– Community reinforcement

– Relapse prevention

– Preventative efforts via education

Summary of Substance-Related Disorders

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

– Depressants, stimulants, opiates, and hallucinogens

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

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

• Psychosocial Factors Interact with Biological Influences to Produce Substance Disorders

• Treatment of Substance Dependence Is Largely Unsuccessful

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

• Substance-Related Disorders Are 100% Preventable

Summary of Substance-Related Disorders (cont.)

Figure 11.x1 (cont.)

Exploring substance-related disorders

Summary of Substance-Related Disorders (cont.)

Figure 11.x2

Exploring substance-related disorders, treatment

Summary of Substance-Related Disorders (cont.)

Figure 11.x2 (cont.)

Exploring substance-related disorders, treatment

Web sites

• National Clearinghouse for Alcohol and Drug Information

– www.health.org

• National Institute on Drug Abuse

– www.nida.nih.gov

• Inhalants

– www.inhalants.org

• Substance Abuse and Mental Health Services Administration

– www.samhsa.gov

Impulse-Control Disorders

• DSM-IV-TR

– Intermittent explosive disorder

– Kleptomania

– Pyromania

– Pathological gambling

– Trichotillomania

Impulse-Control Disorders (continued)

• Each is Characterized by

– Increased tension/anxiety prior to the act

– A sense of relief following the act

– Impairment of social and occupational functioning

Impulse-control Disorders: Intermittent Explosive Disorder

• Intermittent Explosive Disorder

– Rare condition

– Characterized by frequent aggressive outbursts

– Leads to injury and/or destruction of property

– Few controlled treatment studies

Impulse-control Disorders: Kleptomania

• Kleptomania

– Failure to resist urge to steal unnecessary items

– Seems rare, but it is not well studied

– Highly comorbid with mood disorders

– Also co-occurs with substance-related problems

Impulse-control Disorders: Pyromania, Pathological Gambling

• Pyromania

– Involves having an irresistible urge to set fires

– Diagnosed in less than 4% of arsonists

– Little etiological and treatment research

• Pathological Gambling

– Affect 3-5% adult Americans

– Treatment is similar to that for substance dependence

Trichotillomania (continued)

• Trichotillomania

– Inability to resist the urge to pull hair

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

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