Substance-Related and Impulse Control Disorders

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Substance-Related and Impulse Control Disorders
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Levels of Involvement Substance Disorders
Terminology

• Rate of use illegal substances 8
• Specific drugs have specific effects, but
  terminology applies to all

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• Psychoactive substances alter mood or behavior
• Substance use moderate ingestion of psychoactive
  substances, does not interfere with functioning

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Intoxication

• Intoxication physiological reactions resulting
  from ingestion of psychoactive substance
• Impaired judgment
• Changes in motor ability
• Mood changes

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Substance Abuse

• Substance abuse pattern of substance use that
  leads to significant distress or impairment in
  roles, and in hazardous situations

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Substance Dependence

• Substance dependence characterized by need for
  increased amounts to achieve desired effect
  (tolerance)
• Negative physical effects when withdrawn
  (withdrawal)

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Substance Dependence

• Dependence is also marked by
• Unsuccessful attempts at control
• Substantial effort expended to seek
• Substantial effort to recover

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Psychiatric Definition 3 of 9 required for
addiction

• TAKES more than intended
• WANTS to cut back, but has failed
• SPENDS lots of time trying to get or do
• OFTEN intoxicated or in withdrawal
• CURTAILS other activities

• USES substance despite problems it causes
• NEEDS more and more of substance to achieve
  effect
• SUFFERS withdrawal
• TAKES substance to avoid withdrawal

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Relative Addictiveness Based on Expert Ratings
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Diagnostic Specifics

• Diagnoses are given by
• Substance
• Dependence, abuse, intoxication, withdrawal
• Other disorders can complicate picture

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Individual Substances

1. Depressants sedation, relaxation. Include
   alcohol, sedative drugs
2. Stimulants increase activity, alertness, mood.
   Amphetamines, cocaine, nicotine, caffeine
3. Opiods reduce pain and increase euphoria.
   Heroin, opium, morphine
4. Hallucinogens alter sensory perception.
   Marijuana, LSD

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Depressants

• Alcohol
• Sedatives

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Alcohol Abuse

• 23 Americans binge drink (5)
• 15 million Americans are alcohol dependent
• Very culturally dependent
• Peru 25
• Shanghai 0.45
• Dependency is chronic
• Earlier age (11-14) increased risk disorder

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Sedative Use Disorders

• Calming, sleep-inducing, anxiety reducing
• Barbituates ?
• Common use for suicide (suffocation)
• Benzodiazepines ?
• Less than 1 of treatment seekers

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Description Effects of Alcohol

• Initial depression of inhibitory centers
• Spreads to motor coordination, reaction time,
  judgments, etc
• Withdrawal can be severe
• Hand tremors, nausea vomiting, anxiety,
  hallucinations, insomnia, agitation, delirium
• Long-term abuse can lead to dementia

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Stimulants

• Amphetamines
• Cocaine
• Nicotine
• Caffeine

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Amphetamine Use Disorders

• Elation ? Crashing
• Man-made
• asthma, nasal decongestant
• Weight loss, narcolepsy, ADHD

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Diagnostic criteria

• Behavioral symptoms
• Changes in affect
• Sociability, interpersonal sensitivity
• Anxiety, anger
• Impaired judgment
• Quick tolerance

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Cocaine Use Disorders

• Short-lived high, paranoia is common (2/3)
• Dependence is different
• Inability to resist increases
• Few early negative effects
• Lack of sleep, paranoia
• Withdrawal leads to severe apathy

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Opiods

• Natural, synthetic, endogenous to body
• Euphoria, drowsiness, slowed breathing
• Analgesics (e.g., morphine)
• Very unpleasant withdrawal
• 6-12 hours
• Yawning, nausea, vomiting, chills, muscle aches,
  diarrhea, insomnia (1-3 days)
• Poor prognosis

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Hallucinogens (LSD)

• Synthetically produced
• Quick tolerance
• Lack of effect over days
• Little reported withdrawal
• Mechanism unknown
• Long-term effects unknown

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Other Substances of Abuse

• Inhalants
• Most common poor adolescent males
• Steroids
• Designer drugs

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Causes of Substance Abuse Disorders

• Biological Factors
• Genetic
• Neurobiological
• Psychological Factors
• Reinforcement
• Cognitive Factors
• Social Factors
• Culture
• Integrative Model

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Biological Influences - Genes

• Drug abuse (particularly alcohol) have genetic
  influence
• Easiest to study alcohol
• Common genetics?
• Use environment, abuse genetic?

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Biological Influences - Neurobiology

• Positive reinforcement of natural pleasure states
  neurologically
• Dopaminergic system opiods
• How does negative reinforcement work?

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Psychological Influences Positive and Negative
Reinforcement

• Positive reinforcement can be physical
• Also social
• Negative reinforcement relief (Such as anxiety,
  pain, etc.)
• Used to self medicate

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Cognitive Factors

• Expectancy effects
• Predict future drinking use by teens
• Drinking will improve social behavior, motor, and
  cognitive abilities
• Expectancies might result from us
• Cravings
• Influenced by cognitions availability,
  environment, moods

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Social Factors

• Exposure to substances influences disorder
  development
• Media exposure, peer exposure
• Less monitoring by parents with disorder

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Cultural Influences

• Cultural expectations for drug use
• Economic influences

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An Integrative Model

• Textbook p. 415
• All influences work together to increase
  likelihood of substance disorder
• Also influences the maintenance of that disorder
• Equifinality a particular disorder can arise
  from multiple and different paths

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Treatment of Substance-Related Disorders

• Personal motivation is essential
• Difficult and slow
• Individualized
• Treatments across type of drug very similar
• Biological Treatments
• Psychosocial Treatments

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Biological Treatments Agonist Substitution

• Patient is provided with safe drug that has
  similar chemical makeup
• E.g. methadone (opiod) for heroin
• No high, but same analgesic and sedation
• Results are mixed
• Cross-tolerance
• Abuse of other drugs
• Lifelong dependency

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Biological Treatments Antagonist Treatment

• Effects of drug are blocked, so no longer produce
  pleasant results
• Naltrexone produces immediate withdrawal
  symptoms from opiods
• Might also help with alcoholism, with therapy

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Biological Treatments Aversive Treatment

• Make ingesting psychoactive drug unpleasant
• Associate drug use with side effects
• Antabuse
• Nausea, vomiting, elevated heart rate,
  respiration
• Noncompliance is large problem

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Psychological Treatments

1. Inpatient treatment
2. Alcoholics Anonymous (and variants)
3. Controlled Use
4. Component Treatment
5. Relapse Preventions

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Inpatient Treatment

• Help addicts through initial withdrawal
• Expensive
• May be no difference between inpatient and
  outpatient care
• Environment is different

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Alcoholics Anonymous

• Developed 1935
• Alcoholism as a disease that requires lifelong
  management
• High levels of social support
• 97,000 groups in 100 countries
• 3 of Americans report attending at least 1
  meeting in their lifetime
• Relies on prayer and belief in higher power
• Research on AA is very difficult

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Controlled Use

• Alternative to total abstinence
• Some may become social users
• Extremely controversial
• both controlled use and abstinence is successful
  for only 20-30 of patients

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Component Treatment

• Aversion therapy use paired with punishment
• Covert sensitization
• Contingency management rewards
• Community reinforcement address life
• Close other participates
• Identify antecedents and consequences
• Assistance with social services
• New recreational activities

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Relapse Prevention

• Learned aspects of dependence
• Relapse failure of cognitive and behavioral
  coping skills
• Target ambivalence
• Positive aspects
• Negative consequences
• Identify high risk situations and plan

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Impulse-Control Disorders

1. Intermittent Explosive Disorders
2. Kleptomania
3. Pyromania
4. Pathological Gambling
5. Trichotillomania
6. Problematic Internet Use

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Intermittent Explosive Disorder

• Aggressive impulses
• Result in serious assault or destruction of
  property
• Rarely diagnosed
• Symptoms often accounted for by another disorder

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Kleptomania

• Urges to steal things
• Not needed for personal use or monetary value
• Rare? (Difficult to study)
• Urge brings sense of tension, which is relieved
  by stealing

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Pyromania

• Urge to set fires
• Pattern similar to kleptomania (tension relief)
• Less than 4 of arsonists
• Very little research

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Pathological Gambling

• Increasing number of patients
• 3-5 of adult Americans
• Increasing among adolescents
• Similar criteria to substance abuse
• Increasing amounts for high
• Withdrawal
• Interference with functioning

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Pathological Gambling

• fMRIs show decreased activation in regions of
  brain that regulate impulses, while gambling
• Abnormalities in dopamine and serotonin
• Gamblers Anonymous
• 70-90 drop out
• Need high motivation

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Trichotillomania

• Urge to pull out ones hair
• 1-5 of college students
• Greater incidence in females
• Antidepressants Cognitive therapy seem to have
  effect
• Research is very scarce

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Internet Addiction

• Excessive gaming, sexual preoccupation, and/or
  email/text use
• Excessive Use
• Loss of time, neglect of basic drives
• Withdrawal
• Anger, tension, depression when inaccessible
• Tolerance
• Better equipment, new software, longer times
• Negative Repercussions
• Lying, arguments, academic achievements, social
  isolation

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Internet Addiction

• Difficult to research
• In US, Internet and computers are accessed from
  home
• 86 estimated to have comorbidity
• Shame, denial, motivation, lack of awareness
• Estimated 0.3-0.7 prevalence in US