Announcement

1. Substance Use Disorders II(Chapter 11)April 4, 2014PSYC 2340: Abnormal PsychologyBrett Deacon, Ph.D.

2. Announcement • Exam 3 is next Friday

3. From Last Class • Biological influences in eating disorders, and politics • Eating disorders treatment • Substance use disorders: diagnostic criteria for abuse and dependence • Alcohol • Effects of use • American ambivalence

4. DSM-IV: Somatoform Disorders • Problems characterized by physical symptoms without an underlying medical cause

5. DSM-5: Somatic Symptom Disorder • Somatic symptom disorder • A. One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.  • B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns as manifested by at least one of the following: • (1) Disproportionate and persistent thoughts about the seriousness of one's symptoms. • (2) Persistently high level of anxiety about health or symptoms • (3) Excessive time and energy devoted to these symptoms or health concerns  • C. Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months) • Specify if with predominant pain

6. DSM-5: Somatic Symptom Disorder • What’s missing? • Presence of known medical basis of somatic symptoms vs. medically unexplained symptoms • What constitutes excessive concern about a serious medical problem?

7. DSM-5: Somatic Symptom Disorder • Very controversial! • Pathologizes normal reactions to distressing symptoms, especially those with a proven medical basis • Will dramatically increase rates of mental disorder diagnoses in the medically ill • 1 in 6 cancer and heart disease patients • 1 in 4 patients with irritable bowel syndrome and chronic pain

8. In the News • Justina Pelletier • Background • Spent the past year in a locked psych ward • http://www.behaviorismandmentalhealth.com/2014/04/04/justina-pelletier-the-case-continues/ • Judge awarded permanent custody to state • “At trial there was extensive psychiatric and medical testimony. Voluminous psychiatric and medical records were entered in evidence. Based on credible psychiatric and medical evidence this court has found that Justina suffers from a persistent and severe Somatic Symptom Disorder. On December 20, 2013, this court found the MA DCF sustained its burden by clear and convincing evidence that Justina Pelletier is a child in need of care and protection pursuant to G.L c. 119, §§ 24-26 due to the conduct and inability of her parents, Linda Pelletier and Lou Pelletier, to provide for Justina’s necessary and proper physical, mental, and emotional development.”

9. For Today • Cultural influences on alcohol use • Health effects of alcohol consumption • Disease model of alcoholism and Twelve Step Treatment

10. Culture and Alcohol Use • Major cultural differences in patterns of use • Abstinence vs. abuse • Frequent use, low abuse – Italians, Chinese, Jewish, Greek(my experience in Greece) • Lower use, frequent abuse – Americans, Irish

11. Culture and Alcohol Use When an American clinician, William Miller, ventured to Europe, he observed "huge national differences in what is recognized to be a harmful amount of alcohol consumption": The American samples that I have defined as "problem drinkers" in my treatment studies have reported, at intake, an average consumption of approximately 50 drinks per week. In Norway and Sweden, the audiences tended to be shocked by this amount of drinking and argued that my samples must consist of chronic addicted alcoholics. In Scotland and Germany, on the other hand, the skepticism tended to be aimed at whether these individuals had a real problem at all because this level was regarded as quite ordinary drinking. Peele, 1993; http://www.peele.net/lib/publhlth.html

12. Culture and Alcohol Use • Cultures with a temperance movement (“temperance cultures”) • Example: Prohibition in the US • Includes US, Great Britain, Australia, New Zealand, Finland, Sweden, Norway, Iceland • Non-temperance cultures: Austria, Belgium, Denmark, France, Italy, the Netherlands, Portugal, Spain, Switzerland, Germany Peele, 1993; http://www.peele.net/lib/publhlth.html

13. Culture and Alcohol Use Peele, 1993

14. Differences between Temperance and Non-Temperance Cultures • 1. Temperance cultures are much more concerned with the dangers of alcohol • 2. Temperance cultures drink considerably less alcohol (i.e., more abstainers) • 3. Temperance cultures consume more alcohol in form of hard liquor

15. Differences between Temperance and Non-Temperance Cultures • 4. Nontemperance cultures consume more alcohol in form of wine • 5. Temperance cultures have significantly higher rates of deaths from heart disease

16. Conceptions of Alcohol Use • Why do we see this pattern of alcohol use in temperance cultures? • Differences in views of alcohol and its appropriate use • Typical pattern of alcohol use in non-temperance cultures among young people

17. Conceptions of Alcohol Use • Common pattern of alcohol use in America among young people • In the U.S., children whose parents introduced drinking to them at home were one-third as likely to binge in high school • In the US, ambivalence about alcohol and the AA/disease model prevail • A few words on the health benefits of moderate alcohol consumption…

18. Health Benefits of Moderate Alcohol Use • Moderate drinking: 1-2 drinks per day for women and 2-4 drinks per day for men • Moderate drinkers live longer than abstainers • Moderate drinkers have lower rates of Alzheimer’s disease, and are mentally sharper in old age • Moderate drinking associated with: less hospitalization, better general health, less work absenteeism, less disability, less lethal heart attacks, fewer strokes, lower blood pressure, less diabetes

19. Wine, Beer, or Liquor: Does it Matter? • Rimm et al. (1996). Review of moderate alcohol consumption and reduced risk of coronary heart disease: is the effect due to beer, wine, or spirits. British Medical Journal, 312, 731-736. • “CONCLUSIONS: Results from observational studies, where alcohol consumption can be linked directly to an individual's risk of coronary heart disease, provide strong evidence that all alcoholic drinks are linked with lower risk. Thus, a substantial portion of the benefit is from alcohol rather than other components of each type of drink.”

20. Health Benefits of Moderate Alcohol Use • What’s the leading cause of death? • “On the basis of its extensive review of research, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) reported that moderate drinkers have the greatest longevity. It also found that moderate drinking is beneficial to heart health, resulting in a sharp decrease in heart disease risk (40%-60%). This is important because cardiovascular disease is the number one cause of death in the United States, and heart disease kills about one million Americans each and every year.” • Reference: Highlights of the NIAAA position paper on moderate alcohol consumption. Press release from the journal, Alcoholism: Clinical & Experimental Research, June 14, 2004.

21. Alcohol and Heart Disease

22. Advice from the American Heart Association • “We do not believe that physicians and other health care providers should advocate [behavior that reduces the risk of the leading cause of death by 40% to 60%] but rather should continue to advocate and address the importance of other lifestyle behaviors.”

23. Advice from the American Heart Association • Actual quote: “We do not believe that physicians and other health care providers should advocate the use of wine or other alcoholic beverages as health promoting substances but rather should continue to advocate and address the importance of other lifestyle behaviors.”

24. The Benefits of Alcohol Factors that affect public views of alcohol: • 1. Most prominent medical and public health authorities damn alcohol at every turn. • 2. Even researchers who find benefits from alcohol seem reluctant to describe them. • “Because of the potential for alcohol to be abused, the researchers do not recommend that abstainers begin drinking.” (Collins et al., 2009) • “Until we can be sure that advice that encourages the public to drink to avoid coronary heart disease does not increase abuse, we must be cautious in making general recommendations.” (Kannel & Ellison, 1996) • “Few medical experts, if any, advise nondrinkers to start drinking.” http://www.mayoclinic.com/health/alcohol/SC00024 Peele, 1993; http://www.peele.net/lib/publhlth.html

25. The Benefits of Alcohol Factors that affect public views of alcohol: • 3. No American medical body will recommend drinking as healthful. • A recent exception, from the US Department of Agriculture’s 2010 Dietary Guidelines: • "Alcohol consumption may have beneficial effects when consumed in moderation (up to two drinks daily). Strong evidence from observational studies has shown that moderate alcohol consumption is associated with a lower risk of cardiovascular disease. Moderate alcohol consumption also is associated with reduced risk of all-cause mortality among middle-aged and older adults and may help to keep cognitive function intact with age."

26. The Benefits of Alcohol • 4. According to the data, alcohol has a role as a therapy for coronary artery disease, a role that scares American clinicians. • 5. Americans would not drink more even if we told them to. • 6. Those we tell not to drink also do not listen to us.

27. On The Benefits of Alcohol… “The view that people are so stupid or malleable that they will become alcohol abusers because doctors tell them that moderate drinking is good for them is demeaning and self-defeating. If people can't regulate their own diets, drinking, and exercise, then doctors should avoid giving patients any information about their health behavior, no matter how potentially helpful.” – Psychologist Stanton Peele

28. Fetal Alcohol Syndrome • CDC estimates rate of 2.7/1000 live births • Fetal growth retardation, cognitive deficits, behavior problems, learning difficulties • Occurs in 2%-10% of children of alcohol abusers (not alcohol users) • More common in African Americans and Native Americans than Caucasians

29. Fetal Alcohol Syndrome • Effects of low-moderate maternal alcohol consumption (< 1 drink per day average) on the fetus • Henderson et al. (2007) http://www3.interscience.wiley.com/cgi-bin/fulltext/118523339/PDFSTART • Combined results from 46 studies • Examined effects on miscarriage, stillbirth, intrauterine growth restriction, prematurity, birthweight, small for gestational age at birth and birth defects including fetal alcohol syndrome • Findings: “This systematic review found no convincing evidence of adverse effects of prenatal alcohol exposure at low–moderate levels of exposure. At low–moderate levels of consumption, there were no consistently significant effects of alcohol on any of the outcomes considered.”

30. Fetal Alcohol Syndrome • Plenty of evidence that repeated abusive heavy drinking is associated with FAS and related problems • FAS usually occurs with chronically alcoholic mother who binged during pregnancy • Third variable problem – smoking, malnutrition, poor health care

31. Disease Model of Alcoholism • Alcoholism has the “original” disease model in abnormal psychology • Hybrid biological/moral/spiritual disease • Disease model popularized by Alcoholics Anonymous (AA) and Twelve Step treatments • Model dominates addictions treatment; AA is by far the most common alcohol treatment program in the world • Legally mandated AA treatment is common

32. The Disease Model of Alcoholism “…first we were smitten by an insane urge that condemned us to go on drinking, and then by an allergy of the body that insured we would ultimately destroy ourselves in the process.” -from Twelve Steps and Twelve Traditions, Alcoholics Anonymous World Services

33. Disease Model of Alcoholism • Core tenets of disease model of alcoholism: • Powerlessness/loss of control • Inherited biological “allergy” to alcohol • Inevitable progression, treatment is necessary • Abstinence (AA) is only possible treatment • Denial is a core symptom of alcoholism

34. Disease Model of Alcoholism • Controversies with disease model and treatment: • Are people really powerless over their alcohol use? • Are people personally responsible for their alcohol use? • Should permanent abstinence be the only treatment option for everyone? • Is denial a characteristic of alcoholism or of coercive treatment?

35. Alcoholics Anonymous and the Disease Model of Alcoholism • http://www.southparkstudios.com/clips/155147/dads-drunk • http://www.southparkstudios.com/clips/103662/randys-dui • http://www.southparkstudios.com/clips/155150/a-big-loser-like-stans-dad • http://www.southparkstudios.com/clips/103665 • http://www.southparkstudios.com/clips/155157 • http://www.southparkstudios.com/clips/155164