Comer, Abnormal Psychology, 8th edition

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Substance Use Disorders
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Substance Use Disorders

• Some substances can also lead to long-term
  problems
• People who regularly ingest them may develop
  substance use disorders
• Also called addiction

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Substance Use Disorders
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Substance Use Disorders
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Depressants

• Depressants slow the activity of the central
  nervous system (CNS)
• Reduce tension and inhibitions
• May interfere with judgment, motor activity, and
  concentration
• Three most widely used depressants
• Alcohol
• Sedative-hypnotic drugs
• Opioids

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Depressants Alcohol

• All alcoholic beverages contain ethyl alcohol
• It is absorbed into the blood through the stomach
  lining and takes effect in the bloodstream and
  CNS
• Short-term alcohol blocks messages between
  neurons
• Alcohol helps GABA (an inhibitory messenger) shut
  down neurons and relax the drinker

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Depressants Alcohol

• The extent of the effect of ethyl alcohol is
  determined by its concentration (proportion) in
  the blood
• A given amount of alcohol has a lesser effect on
  a large person than on a small one
• Gender also affects blood alcohol concentration
• Women have less alcohol dehydrogenase, an enzyme
  in the stomach that metabolizes alcohol before it
  enters the blood
• Women become more intoxicated than men on equal
  doses of alcohol

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Depressants Alcohol

• Levels of impairment are closely tied to the
  concentration of ethyl alcohol in the blood
• BAC 0.06 Relaxation and comfort
• BAC 0.09 Intoxication
• BAC gt 0.55 Death
• Most people lose consciousness before they can
  drink this much

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Depressants Alcohol

• The effects of alcohol subside only after alcohol
  is metabolized by the liver
• The average rate of this metabolism is 25 of an
  ounce per hour
• You can't increase the speed of this process!

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Depressants Alcohol
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Is All Drug Misuse the Same? DSM-5 has combined
two past disorders, substance abuse (excessive
and chronic reliance on drugs) and substance
dependence (excessive reliance accompanied by
tolerance and withdrawal symptoms) into a single
categorysubstance use disorder. Critics worry
that clinicians may now fail to recognize and
address the different prognoses and treatment
needs of individuals who abuse substances and
those who depend on substances.
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Depressants Alcohol

• Alcohol use disorder
• In general, people who abuse alcohol drink large
  amounts regularly and rely on it to enable them
  to do things that would otherwise make them
  anxious
• Eventually the drinking interferes with social
  behavior and the ability to think and work
• Individual patterns of alcohol abuse vary

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Depressants Alcohol

• Alcohol dependence
• For many people, the pattern of alcohol misuse
  includes dependence
• They build up a physiological tolerance and need
  to drink greater amounts to feel its effects
• They may experience withdrawal, including nausea
  and vomiting, when they stop drinking
• A small percentage of alcohol-dependent people
  experience a dramatic and dangerous withdrawal
  syndrome known as delirium tremens (the DTs)
• Alcohol withdrawal can be fatal

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What is the personal and social impact of
alcoholism?
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Depressants Sedative-Hypnotic Drugs

• Sedative-hypnotic (anxiolytic) drugs produce
  feelings of relaxation and drowsiness
• At low doses, they have a calming or sedative
  effect
• At high doses, they function as sleep inducers or
  hypnotics
• Sedative-hypnotic drugs include barbiturates and
  benzodiazepines

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Depressants Barbiturates

• Widely prescribed in the first half of the 20th
  century to fight anxiety and to help people sleep
• They can cause many problems such as abuse,
  dependence, and overdose
• At low doses, they reduce excitement in a manner
  similar to alcohol by attaching to the GABA
  receptors and helping GABA operate
• At too high a level, they can halt breathing,
  lower blood pressure, and can lead to coma and
  death

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Depressants Barbiturates

• Repeated use of barbiturates can quickly result
  in a pattern of abuse and/or dependence
• A great danger of barbiturate dependence is that
  the lethal dose of the drug remains the same,
  even while the body is building a tolerance for
  the sedative effects
• Barbiturate withdrawal is particularly dangerous
  because it can cause convulsions

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Depressants Benzodiazepines

• Benzodiazepines are often prescribed to relieve
  anxiety
• Most popular sedative-hypnotics available
• Class includes Xanax, Ativan, and Valium
• Benzodiazepines have a depressant effect on the
  CNS by binding to GABA receptors and increasing
  GABA activity
• Benzodiazepines relieve anxiety without causing
  drowsiness
• Less likely to slow breathing and lead to death
  by overdose

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Depressants Opioids

• This class of drug includes both natural (opium,
  heroin, morphine, codeine) and synthetic
  (methadone) compounds and is known collectively
  as narcotics
• Each drug has a different strength, speed of
  action, and tolerance level

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Depressants Opioids

• Narcotics are smoked, inhaled, injected by needle
  just under the skin (skin popped), or injected
  directly into the bloodstream (mainlined)
• Injection seems to be the most common method of
  use, although other techniques have been
  increasing in recent years
• An injection quickly brings on a rush a spasm
  of warmth and ecstasy that is sometimes compared
  with orgasm
• This spasm is followed by several hours of
  pleasurable feelings (called a high or nod)

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Depressants Opioids

• Opioids create these effects by depressing the
  CNS
• Opioids bind to the receptors in the brain that
  ordinarily receive endorphins (NTs that naturally
  help relieve pain and decrease emotional tension)
  
• When these sites receive opioids, they produce
  pleasurable and calming feelings, just as
  endorphins do
• In addition to reducing pain and tension, opioids
  can cause nausea, narrowing of the pupils, and
  constipation

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Depressants Opioids

• Heroin use exemplifies the problems posed by
  opioids
• After just a few weeks, users may become caught
  in a pattern of abuse (and often dependence)
• Users quickly build a tolerance for the drug and
  experience withdrawal when they stop taking it
• Early withdrawal symptoms include anxiety and
  restlessness later symptoms include twitching,
  aches, fever, vomiting, diarrhea, and weight loss
  from dehydration

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Depressants Opioids

• What are the dangers of heroin abuse?
• The most immediate danger is overdose
• The drug closes down the respiratory center in
  the brain, paralyzing breathing and causing death
• Death is particularly likely during sleep
• Ignorance of tolerance is also a problem
• About 2 of those dependent on heroin and other
  opioids die under the influence of the drug each
  year
• Users run the risk of getting impure drugs
• Opioids are often cut with noxious chemicals
• Dirty needles and other equipment can spread
  infection

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Stimulants

• Stimulants are substances that increase the
  activity of the central nervous system (CNS)
• Cause increases in blood pressure, heart rate,
  and alertness
• Cause rapid behavior and thinking
• The four most common stimulants are
• Cocaine
• Amphetamines
• Caffeine
• Nicotine

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Stimulants Cocaine

• Most powerful natural stimulant known
• Cocaine produces a euphoric rush of well-being
• Produces this effect largely by increasing
  supplies of dopamine at key neurons throughout
  the brain
• Also appears to increase norepinephrine and
  serotonin

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Stimulants Cocaine

• High doses of cocaine can produce cocaine
  intoxication, whose symptoms include mania,
  paranoia, and impaired judgment
• Some people also experience hallucinations and/or
  delusions, a condition known as cocaine-induced
  psychotic disorder
• As the stimulant effects of the drug subside, the
  user experiences a depression-like letdown,
  popularly called crashing

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Stimulants Cocaine

• Cocaine abuse and dependence
• Regular use may lead to a pattern of abuse in
  which the person remains under the effect of
  cocaine for much of each day and functions poorly
  in social relationships and at work
• Dependence on the drug may also develop

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Stimulants Cocaine

• Cocaine abuse and dependence
• Cocaine use in the past was limited by the drug's
  high cost
• Since 1984, cheaper, more powerful versions of
  the drug have become available, including
• A freebase form where the drug is heated and
  inhaled with a pipe
• Crack, a powerful form of freebase that has
  been boiled down for smoking in a pipe
• Currently, 0.5 of all people over the age of 11
  in the U.S. manifest cocaine abuse or dependence
  in a given year

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Stimulants Cocaine

• What are the dangers of cocaine?
• Aside from its behavioral effects, cocaine poses
  significant physical danger
• The greatest danger of use is the risk of
  overdose
• Excessive doses depress the brain's respiratory
  function, and stop breathing
• Cocaine use can also cause heart failure
• Pregnant women who use cocaine have an increased
  likelihood of miscarriage and of having children
  with abnormalities

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Stimulants Amphetamines

• Amphetamines stimulant drugs manufactured in the
  laboratory
• Most often taken in pill or capsule form
• Some people inject the drugs intravenously or
  smoke them for a quicker, more powerful effect
• Like cocaine, amphetamines
• Increase energy and alertness and reduce appetite
  when taken in small doses
• Produce a rush, intoxication, and psychosis in
  high doses
• Cause an emotional letdown as they leave the body

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Stimulants Amphetamines

• One kind of amphetamine, methamphetamine, has had
  a major surge in popularity in recent years
• Almost 6 of all persons over the age of 11 in
  the US have used this stimulant at least once
• Most of the nonmedical meth is made in stovetop
  laboratories

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Stimulant Use Disorder

• Regular use of either cocaine or amphetamines may
  lead to stimulant use disorder
• The stimulant dominates the individuals life
• Leads to poor function in social relationships
  and at work

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Stimulants Caffeine

• Worlds most widely used stimulant
• 80 of the world's population consumes it daily
• Most is in the form of coffee the rest is in the
  form of tea, cola, energy drinks, chocolate, and
  over-the-counter medications
• 99 of ingested caffeine is absorbed by the body
  and reaches its peak concentration within an hour
• Caffeine acts as a stimulant in the CNS,
  producing a release of dopamine, serotonin, and
  norepinephrine in the brain
• More than 2 to 3 cups of brewed coffee can lead
  to caffeine intoxication
• Seizures and respiratory failure can occur at
  doses greater than 10 grams of caffeine (about
  100 cups of coffee)

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Stimulants Caffeine

• Many people who suddenly stop or cut back their
  usual intake experience withdrawal symptoms,
  including headaches, depression, anxiety, and
  fatigue
• Studies suggest correlations between high doses
  of caffeine and heart rhythm irregularities, high
  cholesterol levels, and risk of heart attacks
• High doses during pregnancy also increase the
  risk of miscarriage

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Hallucinogens, Cannabis, and Combinations of
Substances

• Hallucinogens
• Produce delusions, hallucinations, and other
  sensory changes
• Cannabis substances
• Produce sensory changes, but have both depressant
  and stimulant effects
• Combinations of substances

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Hallucinogens

• Hallucinogens produce powerful changes in sensory
  perceptions (sometimes called trips)
• Natural hallucinogens
• Mescaline
• Psilocybin
• Laboratory-produced hallucinogens
• Lysergic acid diethylamide (LSD)
• MDMA (Ecstasy)

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Hallucinogens

• LSD is one of the most powerful hallucinogens
• Brings on a state of hallucinogen intoxication
  (hallucinosis)
• Increased and altered sensory perception
• Hallucinations and/or synesthisia
• Effects wear off in about six hours
• LSD produces these symptoms by binding to
  serotonin receptors
• These neurons help control visual information and
  emotions, thereby causing the various effects of
  the drug on the user

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Hallucinogens

• More than 14 of Americans have used
  hallucinogens at some point in their lives
• Tolerance and withdrawal are rare
• But the drugs do pose dangers
• Users may experience a bad trip the
  experience of enormous unpleasant perceptual,
  emotional, and behavioral reactions
• Another danger is the risk of flashbacks
• Can occur days or months after last drug use

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Cannabis

• The drugs produced from varieties of the hemp
  plant are, as a group, called cannabis
• They include
• Hashish, the solidified resin of the cannabis
  plant
• Marijuana, a mixture of buds, crushed leaves, and
  flowering tops
• The major active ingredient in cannabis is
  tetrahydrocannabinol (THC)
• The greater the THC content, the more powerful
  the drug

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Cannabis

• When smoked, cannabis produces a mixture of
  hallucinogenic, depressant, and stimulant effects
• At low doses, the user feels joy and relaxation
• May become anxious, suspicious, or irritated
• This overall high is technically called
  cannabis intoxication
• At high doses, cannabis produces odd visual
  experiences, changes in body image, and
  hallucinations
• Most of the effects of cannabis last 2 to 6 hours
• Mood changes may continue longer

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Cannabis abuse and Dependence

• Marijuana was once thought not to cause abuse or
  dependence
• One theory about the increase in abuse and
  dependence is the change in the drug itself
• The marijuana available today is significantly
  more potent than the drug used in the early 1970s

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Cannabis
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Cannabis

• Cannabis and Society A Rocky Relationship
• For centuries, cannabis played a respected role
  in medicine, but its use fell out of favor and
  was criminalized
• In the late 1980s, several interest groups
  campaigned for the medical legalization of
  marijuana
• The U.S. Federal Government has continued to
  fight and punish the production and distribution
  of marijuana for medical purposes
• However, in 2009, the US Attorney General
  directed federal prosecutors to not pursue cases
  against medical marijuana users complying with
  state laws
• Both the Netherlands and Canada permit its use

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Teenagers and Substance Use
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Combinations of Substances

• People often take more than one drug at a time, a
  pattern called polysubstance use
• Researchers have studied the ways in which drugs
  interact with one another, focusing on
  cross-tolerance and synergistic effects

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Combinations of Substances
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Combinations of Substances
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Combinations of Substances
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Combinations of Substances

• Each year tens of thousands of people are
  admitted to hospitals because of polysubstance
  use
• May be accidental or intentional
• As many as 90 of people who use one illegal drug
  are also using another to some extent

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What Causes Substance Use Disorders?

• Clinical theorists have developed sociocultural,
  psychological, and biological explanations for
  substance abuse and dependence
• No single explanation has gained broad support
• Best explanation a COMBINATION of factors

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Causes of Substance Use Disorders Sociocultural
Views
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Causes of Substance Use Disorders Psychodynamic
Views

• Psychodynamic theorists believe that people who
  abuse substances have powerful dependency needs
  that can be traced to their early years
• Caused by a lack of parental nurturing
• Some people may develop a substance abuse
  personality as a result
• Limited research does link early impulsivity to
  later substance use, but the findings are
  correlational and researchers cannot presently
  conclude that any one personality trait or group
  of traits stands out in substance use disorders

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Causes of Substance Use Disorders
Cognitive-Behavioral Views

• According to behaviorists, operant conditioning
  may play a key role in substance abuse
• They argue that the temporary reduction of
  tension produced by a drug has a rewarding
  effect, thus increasing the likelihood that the
  user will seek this reaction again
• Similarly, the rewarding effects may also lead
  users to try higher doses or more powerful
  methods of ingestion

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Causes of Substance Use Disorders
Cognitive-Behavioral Views

• Other behaviorists have proposed that classical
  conditioning may play a role in substance abuse
  and dependence
• Objects present at the time drugs are taken may
  act as classically conditioned stimuli and come
  to produce some of the pleasure brought on by the
  drugs themselves
• Although classical conditioning may be at work,
  it has not received widespread research support
  as the key factor in such patterns

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Causes of Substance Use Disorders Biological
Views
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Causes of Substance Use Disorders Biological
Views
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Causes of Substance Use Disorders Biological
Views
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Pleasure Centers in the Brain
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Causes of Substance Use Disorders Biological
Views
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How Are Substance Use Disorders Treated?

• Many approaches have been used to treat substance
  use disorders, including psychodynamic,
  behavioral, cognitive-behavioral, and biological,
  along with sociocultural therapies
• Although these treatments sometimes meet with
  great success, more often they are only
  moderately helpful
• Today treatments are typically used in
  combination on both an outpatient and inpatient
  basis

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How Are Substance Use Disorders Treated?

• The value of treatment for substance abuse or
  dependence can be difficult to determine
• Different substance use disorders pose different
  problems
• Many people with substance abuse patterns drop
  out of treatment early
• Some people recover without any intervention at
  all
• Different criteria are used by different clinical
  researchers

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Psychodynamic Therapies

• Psychodynamic therapists first guide clients to
  uncover and work through the underlying needs and
  conflicts that they believe led to the disorder
  then try to help them change their styles of
  living
• Research has not found this model to be very
  effective
• Tends to be of greater help when combined with
  other approaches in a multidimensional treatment
  program

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Behavioral Therapies

• A widely used behavioral treatment is aversion
  therapy, an approach based on classical
  conditioning principles
• Individuals are repeatedly presented with an
  unpleasant stimulus at the very moment they are
  taking a drug
• After repeated pairings, they are expected to
  react negatively to the substance itself and to
  lose their craving for it

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Behavioral Therapies

• Aversion therapy is most commonly applied to
  alcohol abuse/dependence
• In one version, drinking behavior is paired with
  drug-induced nausea and vomiting
• Another version of this approach requires people
  with alcoholism to imagine extremely upsetting,
  repulsive, or frightening scenes while they are
  drinking
• A behavioral approach that has been successful in
  the short-term is contingency management
• This procedure makes incentives contingent on the
  submission of drug-free urine specimens

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Cognitive-Behavioral Therapies

• These treatments help clients identify and change
  the patterns and cognitions contributing to their
  patterns of use
• Relapse-prevention training
• The overall goal is for clients to gain control
  over their substance-related behaviors
• Clients are taught to identify and plan ahead for
  high-risk situations and to learn from mistakes
  and lapses
• This approach is used particularly to treat
  alcohol use also used to treat cocaine and
  marijuana abuse

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Biological Treatments

• Biological approaches may be used to help people
  withdraw from substances, abstain from them, or
  simply maintain their level of use without
  further increases
• These approaches have limited long-term success
  when used alone, but can be helpful when combined
  with other approaches

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Biological Treatments

• Detoxification
• Systematic and medically supervised withdrawal
  from a drug
• Can be outpatient or inpatient
• Two strategies
• Gradual withdrawal by tapering doses of the
  substance
• Induce withdrawal but give additional medication
  to block symptoms
• Detoxification programs seem to help motivated
  people withdraw from drugs
• For people who fail to receive psychotherapy
  after withdrawal, however, relapse rates tend to
  be high

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Biological Treatments

• Antagonist drugs
• As an aid to resist falling back into a pattern
  of substance abuse or dependence, antagonist
  drugs block or change the effects of the
  addictive substance
• Example disulfiram (Antabuse) for alcohol
• Example naloxone for narcotics, naltrexone for
  alcohol

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Biological Treatments

• Drug maintenance therapy
• A drug-related lifestyle may be a greater problem
  than the drug's direct effects
• Example heroin addiction
• Methadone maintenance programs are designed to
  provide a safe substitute for heroin
• Methadone is a laboratory opioid with a long
  half-life, taken orally once a day
• Programs were roundly criticized as substituting
  addictions but are regaining popularity, partly
  because of the spread of HIV/AIDS

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Sociocultural Therapies
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Sociocultural Therapies

• Self-help and residential treatment programs
• Most common Alcoholics Anonymous (AA)
• Offers peer support along with moral and
  spiritual guidelines to help people overcome
  alcoholism
• It is worth noting that the abstinence goal of AA
  directly opposes the controlled-drinking goal of
  relapse prevention training and several other
  interventions for substance misuse this issue
  has been debated for years
• Many self-help programs have expanded into
  residential treatment centers or therapeutic
  communities
• People formerly dependent on drugs live, work,
  and socialize in a drug-free environment while
  undergoing individual, group, and family therapies

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Sociocultural Therapies

• Culture- and gender-sensitive programs
• A growing number of treatment programs try to be
  sensitive to the special sociocultural pressures
  and problems faced by drug abusers who are poor,
  homeless, or members of ethnic minority groups
• Similarly, therapists have become more aware that
  women often require treatment methods different
  from those designed for men

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Sociocultural Therapies

• Community prevention programs
• Perhaps the most effective approach to substance
  use disorders is to prevent them
• Some prevention programs argue for total
  abstinence from drugs, while others teach
  responsible use
• Prevention programs may focus on the individual,
  the family, the peer group, the school, or the
  community at large
• The most effective of these prevention efforts
  focuses on multiple areas to provide a consistent
  message about drug use in all areas of life