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Addiction Models:

Addiction Models:. Dr. Ronald Y.L. Chen Specialist in Psychiatry. Common Reactions from Health Care Providers. Difficult to understand Change rapidly Polydrug abuse No formal training Addicts are difficult patients Not treatable Not profitable No source of referral/networking.

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Addiction Models:

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  1. Addiction Models: Dr. Ronald Y.L. Chen Specialist in Psychiatry

  2. Common Reactions from Health Care Providers • Difficult to understand • Change rapidly • Polydrug abuse • No formal training • Addicts are difficult patients • Not treatable • Not profitable • No source of referral/networking

  3. New Perspectives • Fascinating neuroscience research • Interplay of biological and psychosocial factors • Challenge in clinical practice • Multi-disciplinary approach • New medications: • e.g. buprenorphine; naltrexone (opioids dependence)

  4. Perspective of drug abuse Brain/Mind Social Body

  5. Moral Model (1) • Infringement of societal rules • Punishable crime • Sinful act • Responsible for his/her own action • Longest standing view

  6. Moral Model (2) • Causes: • Spiritual deficit • Conscious choice • Treatment: • Spiritual Guidance • Moral Persuasion • Imprisonment/Social Consequences

  7. Characterological Model (1) • Character problem • “Addictive personality” • Traits include: • Impulsivity • Sensation seeking • low self-esteem • Inability to cope with stressors • Egocentricity • Manipulative • Need for control and power, while feeling impotent and powerless

  8. Characterological Model (2) • Treatment: • Psychotherapy • Identification and modification of self-esteem, interpersonal skills, impulse control, improved boundary setting

  9. Learning Model • Classical conditioning • Operant conditioning • Social learning

  10. Classical Conditioning (1) • Ian Pavlov • A stimulus elicits a certain response • Unconditioned Stimulus (US) • Unconditioned Response (UR) • Conditioned Stimulus (CS) • Conditioned Response (CR)

  11. Classical Conditioning (2) • US (food) elicits UR (salivation) naturally

  12. Classical Conditioning (3) • The neutral stimulus was paired with the US for a number of times

  13. Classical Conditioning (4) • CS (food dish) alone produces CR (salivation)

  14. Classical Conditioning in Addiction • Physiological arousal during drug intake or addictive behaviour becomes conditioned to the specific situation • Interaction with operant conditioning processes

  15. Operant Conditioning • A response is emitted to obtain an outcome • Behaviors operate on the environment to produce consequences • Controlled by its consequences • Reinforcement (positive or negative) and punishment

  16. Operant Conditioning in Addiction • Positive reinforcements: • Excitement • Self-esteem and status • Monetary gains • Social rewards….etc • Negative reinforcements: • Escape from problems in life • Reduction of aversive stress and emotional states….etc

  17. Social Learning • Individuals learn how to behave through a process of modeling and reinforcement • Assimilate and mirror behaviors by observing the actions of others and the consequences of their actions • E.g. successful high-status role models • Emphasized the role of cognition in learning • Memory based; cognitive organisation • Learn which behaviour gain desired reinforcement

  18. Cognitive Model • Dysfunctional cognitions and perceptions as factors contributing to development and maintenance of addictive behaviour • Addicts have more irrational beliefs, and cognitive biases, distortions and errors • These help to maintain addictive behaviors despite harmful effects

  19. Existential Model (1) • Focus on beliefs, attitudes, and values of addicts • Beliefs about oneself and about the role of substance/behaviour in one's life • Benefits greater than cost • Addicts use substance/behaviour to deal with specific problems they believe they have • e.g. lack of confidence in social-sexual dealings

  20. Existential Model (2) • Fulfills essential intrapsychic, interpersonal, and environmental needs • Views about oneself in regard to the addictive problem are crucial for treatment • If the client and therapist see the problem differently, e.g. viewing it as a disease or not, treatment will generally not succeed

  21. Expectancy Model • Observation & exposure to behaviours creates set of beliefs about that behaviour • Outcome expectancies are one set of beliefs • e.g. sugar water but told that it was an emetic, 80% of subjects in one study responded by vomiting • Positive & Negative outcome expectancies • Determine level & pattern of addictive behaviour

  22. Social Model • Disruptive social forces as social stressors • unemployment, poverty, violence, • family dysfunction, gender and age inequities • Addiction is considered to be an adaptation to the resultant misery and unhappiness • Treatment • environmental modification • Reduce social stressors • Availability of substance • Improve social functioning of addicts • Job & social skill training

  23. Biological/Disease Model • Unique, irreversible, and progressive disease • Underlying biological disturbances • Out of addicts own control • Not sinful but sick • Causal Factors • Genetic factors • Constitutional disease/dysfunction • Biological effects of substances • Treatment • Identification and confrontation of the condition • Lifelong abstinence

  24. Intermission (10 mins)

  25. Dopamine System (多巴安)

  26. The nucleus accumbens is activated when a monetary, chocolate, sexual, luxury, or other reward is anticipated The medial prefrontal cortex is activated when a reward is received Richard L. Peterson, 2004

  27. Biopsychosocial Model • Origins are complex, variable and multifactoral • Interaction between biological, psychological and sociocultural factors • combinations, interactions and the weightings of specific factors are different for different individuals • accommodates diversity and respects individual differences • selectively accommodate and respect a broad range of other theories of addiction and program approaches

  28. Biopsychosocial Model: Advantages • focuses attention on the diversity of client needs • client-centered clinical practices • provides a broad and flexible framework for conceptualizing the nature of the problem • provision of a range of program options • consistent with current addiction research

  29. Factors Associated with Persistent Drug Use • Neurobiology: • genetic risk, drug effects on brain functioning • Psychological factors: • classical & operant conditioning, psychopathology • Social factors: • peers, stress, drug a/v, drug using life-style • Adverse effects from addiction: family, job, social

  30. Types of Addiction • Drug, alcohol, chemical • Behavioural addiction • Gambling • Internet • Shopping • Sex • Work • Exercise • …etc.

  31. Experimentation of gateway drugs • Use of drugs with greater dependence liability • Irregular Use, Abuse, Dependence

  32. Substance Abuse (DSM IV) • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home • Recurrent substance use in situations in which it is physically hazardous • Recurrent substance-related legal problems • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance • The symptoms have never met the criteria for Substance Dependence

  33. Dependence Once a person hits the dependents phase, there’s not much voluntary action any more. Addiction becomes more like a chronic disease with relapse and remission. O’Brien CP. A Physician Approach to Treating Addiction. Hospital Practice, April 1997

  34. Substance Dependence (DSM IV) • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: • Tolerance • A need for markedly increased amounts of the substance to achieve intoxication or desired effect • Markedly diminished effect with continued use of the same amount of the substance • Withdrawal • The characteristic withdrawal syndrome for the substance • The substance is taken to relieve or avoid withdrawal symptoms

  35. Substance Dependence (DSM IV) cont. • The substance is often taken in larger amounts or over a longer period than was intended • There is a persistent desire or unsuccessful efforts to cut down or control substance use • A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects • Important social, occupational, or recreational activities are given up or reduced because of substance use • The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

  36. Dependence Central Features • A strong desire or sense of compulsion to take the substance / perform the addictive behaviour • Difficulty controlling substance taking / addictive behaviour • Physiological withdrawal state • Evidence of tolerance • Neglect of alternative pleasure or activities • Persisting with substance use / addictive behaviour despite evidence of harmful consequences • Narrowing personal repertoire to substance use / addictive behaviour

  37. Comprehensive Assessment • Biopsychosocial approach • Identify client’s health & social needs • Help clients to think about why they use the substance and what they should change • Identify mutually agreed treatment goals

  38. Assessment process (1): • Why has the client presented now? • legal problem, health or social reasons • what do they see as a problem? • How has the client presented? • arranged appointment • emergency • accompanied by others

  39. Assessment process (2) • How does the client appear? • unkempt • drowsy, elated, restless • poor concentration • inconsistent history • Any indications of drug use? • needle marks • pupils dilated, constricted • tremor, weight loss • skin lesion, abscess

  40. Assessment Process (3) • Drug history: • initiation of drug use • patterns of drug use (combination, replacement etc.) • when did drug taking become a problem • withdrawal symptoms (may mimic other illnesses) • period of abstinence • level of control • current drug use (route, frequency, dose, setting, source)

  41. Assessment Process (4) • Previous treatment: • in-patient • out-patient • Specialists • Rehabilitation • why relapse • Risk taking behaviour: • unsafe setting e.g. share syringe or other equipment • unsafe sex • aware of HIV, hepatitis B&C etc.

  42. Assessment Process (5) • Assessment of physical health: • any medical problem • any drug related medical problems e.g. abscess, cellulites, thrombosis, septicaemia, bacterial endocarditis, convulsion, TB, hepatitis, HIV

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