Drugs and Substance Abuse

1. Drugs and Substance Abuse on the DSM

2. Drug and Substance Abuseon the DSM Diagnosis: • Substance-induced disorder (effect) • Substance-relateddisorder (cause) ... dependence and abuse

3. Drug and Substance Abuseon the DSM Why drugs? “Life as we find it, is too hard for us; it brings too many pains, disappointments and impossible tasks. In order to bear it, we cannot dispense with palliative measures... there are perhaps three such measures: powerful deflection, which causes to make light our misery; substantive satisfactions, which diminish it; and intoxication, which makes us insensitive to it.” - Freud

4. Drug and Substance Abuseon the DSM Stress: Task-oriented, problem solving vs. Defense oriented, emotion-focused response

5. Drug and Substance Abuseon the DSM • Powerful deflection,which causes to make light our misery; • Substantive satisfactions,which diminish it; • Intoxication,which makes us insensitive to it

6. Drug and Substance Abuseon the DSM Forms of intoxication: 1. Sedation: alcohol, barbituates, benzodiazepines... 2. Stimulation: caffeine, nicotine, amphetamine, cocaine... 3. Fantasy: psychedelics, hallucinogenics, cannabis... 4. Narcotics: opium, morphine, heroin...

7. Drug and Substance Abuseon the DSM Alcohol: BR: 6  8  10%+ LTR: 12  18  20%+ Genetics: concordance and adoption studies (“modelling is a factor”)

8. Drug and Substance Abuseon the DSM Alcohol, biologically: • Increase in some neural activity (e.g. monoamine and endorphin) • Decrease in other neural activity (e.g. GABA and glutamate)

9. Drug and Substance Abuseon the DSM Alcohol, psychologically: • Elevation of positive emotionality • Reduction of negative emotionality

10. Drug and Substance Abuseon the DSM The conditioning perspective: “Alcohol is consumed because it is reinforcing...” • Positive reinforcement • Negative reinforcement

11. Drug and Substance Abuseon the DSM “Types” of alcoholism: • Type I - binge type • Type II – persistent type

12. Drug and Substance Abuseon the DSM Treatment: • Recovery and relapse rates • AA and relapse prevention • “apparently irrelevant decisions” • “abstinence violation effect” • controlled drinking

13. Drug and Substance Abuseon the DSM Comorbidity: • Drug as primary (“primary alcoholism”) • Drug as secondary (“dual diagnosis”)

14. Drug and Substance Abuseon the DSM Related organic disorder: • Alcohol amnestic disorder • “Wernicke-Korsakoff Syndrome” • Vitamin B1 (thiamin) • Alcohol withdrawal delirium • “Delirium tremens” • Fetal alcohol syndrome • “Fetal alcohol spectrum disorder” • BR and other issues

15. Sex on the DSM IV

16. Sexand the DSM IV • Sexual dysfunctions: • desire • arousal • orgasm • pain • Variants and deviations: • paraphilias • gender identity disorders (and sexual orientation)

17. Sexand the DSM IV History: Reverend Sylvester Graham Dr. John Harvey Kellogg

18. Sexand the DSM IV History: Kinsey Masters & Johnson

19. Sexand the DSM IV History: The old “Barbie Doll” approach... and the newer evolutionary one: mental and physical aspects John Money

20. Sexand the DSM IV Understanding our sexuality: Back to basics : Why sex? • What is different about sexual motivation, in evolutionary history? • The adaptive functions of sex: reproduction and beyond

21. Sexand the DSM IV Understanding our sexuality: The design of sexual systems: • “Releasers” (cues and rituals) • “Boundary conditions” (internal and external)

22. Sexand the DSM IV Understanding our sexuality: The process: a. partner location elicit desire b. pretactile sexual interaction  maintain arousal c. tactile sexual interaction  “acception” d. intercourse  “conception” The problem: The invocation and maintenance of motivation (“proception”)

23. Sexand the DSM IV : Sexual Dysfunction I. Sexual Dysfunction Base rates: Men: 31% Women 43%

24. Sexand the DSM IV : Sexual Dysfunction • Desire: hypoactive sexual desire and sexual aversion (diagnosis) Dx issues: • “dysfunction” vs. problem • medical factors

25. Sexand the DSM IV : Sexual Dysfunction • Arousal: SADF and SADM (diagnosis) Dx issues: • “erectile insufficiency” for men • vaginal lubrication for women • the relevance of negative emotional states (anxiety) • the relevance of the autonomic nervous system. (PNS/SNS)

26. Sexand the DSM IV : Sexual Dysfunction • Orgasmic: orgasmic dysfunction and “premature ejaculation” (diagnosis) Dx issues: • the ejaculation for men • the “satisfaction” for women

27. Sexand the DSM IV : Sexual Dysfunction “Premature ejaculation” (diagnosis) Dx issues: comparative and personal criteria

28. Sexand the DSM IV : Sexual Dysfunction • Pain: dyspareunia and vaginismus (diagnosis) Also: “Sexual dysfunction NOS”

29. Sexand the DSM IV : Sexual Dysfunction Sexual Dysfunction Summary: the problematic nature of the human sexual response and its ramifications in society

30. Sexand the DSM IV

31. Sexand the DSM IV

32. Sexand the DSM IV : Sexual Dysfunction Therapies: Masters & Johnson, and beyond Tx issues: • success and spontaneous remission • relationships and individualized assessment

33. Sexand the DSM IV II. Variants and Deviations A. Paraphilias and their relation to “sexual” offenses B. Gender identity and its disorders C. Sexual orientation and the controversy over diagnosis The concept of the “lovemap”

34. Sexand the DSM IV : Variants and Deviations A. Paraphilia: Definition: “. . . reiteratively responsive to and dependent on atypical or forbidden stimulus imagery, in fantasy or practice, for the initiation and maintenance of erotosexual arousal and achievement or facilitation of orgasm.” Note: paraphilias and phobias, as opposed to “fetishes” and “irrational fears”

35. Sexand the DSM IV : Paraphilias Examples: • voyeurism • exhibitionism • fetishes • fetishistic transvestism • pedophilia • zoophilia • frotteurism • sexual sadism and masochism • and others . . .

36. Sexand the DSM IV : Paraphilias Theories:(and what is wrong with them) • Psychodynamic Theory management of impulses • Learning Theory A. Classical conditioning: stimulus association problems: extinction and real life? B. Operant conditioning: reinforcement problems: extinction and real life? C. Cognition:  “arousal transference/misattribution”  problems: self-correction and real life?

37. Sexand the DSM IV : Paraphilias What is wrong with learning theories for paraphilias? e.g. • retrospective observations of paraphillics • prospective observations of the rest of us Asking the right question: “the vandalized lovemap”

38. Sexand the DSM IV : Paraphilias • The limitations of behavior therapies e.g. aversion Tx, punishment, condemnation • Modern approaches to treatment e.g. retraining, restructuring, relapse • Notes: preadaptation and multiplicity • Factors that “scramble lovemaps” psychological and biological • Summary and review • Aphrodisiacs and anti-androgens

39. Sexand the DSM IV Beyond the paraphilias: sexual offences in society 1. Rape: • reported rape ... and all the rest • convicted cases ... and all the rest • power, anger, pain ... and “narcissistic reactance” • the social problem, here, today

40. Sexand the DSM IV : Beyond the paraphilias 2. Child molestation and incest: • Reported rates • Why child molestation? • convicted cases and the context • the case of incest • Notes: • issue of child testimony and “recovered memories” • how harmful is childhood sexual abuse?

41. Sexand the DSM IV : Beyond the paraphilias 3. Sexual sadism and masochism: • “sex is seldom just about sex” • modern diagnostic practice

42. Sexand the DSM IV :Variants and Deviations B. Gender Identity Disorder (GID) Your sex and your gender Development of the “gendermap”: “the relay race” 1. genes 2. prenatal hormones 3. physical appearance 4. learning

43. Sexand the DSM IV : Gender Identity • Unusual results: “intersexual syndromes” A. Adrenogenital syndrome (XX) B. Androgen insensitivity syndrome (XY) • Prenatal hormonal variations and “biasing the brain” • Cross-species comparisions and “hermaphrodites” • Culture and the “transgendered” population

44. Sexand the DSM IV : Gender Identity Disorders Child GID Diagnosis: discordance, distress and the desire to change Prognosis: e.g. “the sissy boy syndrome” • gender • sexual orientation

45. Sexand the DSM IV : Gender Identity Disorders Adult GID Diagnosis:discordance, distress and the desire for change A. Women • FTM, masculinity and gynephilia • “Gender atypicality” among women B. Men • MTF, femininity and androphilia • i.e “Classic / Homosexual TS” • “Gender atypicality” among men • Note: “autogynephilia” • i.e “Non-classic / Heterosexual TS”

46. Sexand the DSM IV : Gender Identity Disorders Therapy:... three possibilities 1. Body  mind ... the transsexual surgical solution ... and the debate 2. Mind  body ... modifying gender identity ... and the debate 3. The alternative ... reduce the distress ... and the debate

47. Sexand the DSM IV : Sexual Orientation C. Sexual Orientation and the DSM What is “sexual orientation”? “Erotosexual attraction only to someone who has the same external body morphology as your own” - John Money

48. Sexand the DSM IV : Sexual Orientation Sexual behavior, desire and romantic attraction • e.g. the Sambians and the rest of us • cross-cultural comparisons • cross-species considerations • same sex sexual behavior • same sex sexual relationships

49. Sexand the DSM IV : Sexual Orientation The surveys: Kinsey and beyond • same-sex sexual behavior? 37%, 13%  20%? • same-sex sexual desire? 50%, 28%  about 40%? • same-sex romantic attraction? males: 3 - 4% females: 1 – 2 %

50. Sexand the DSM IV : Sexual Orientation The modern results: • behavior? 9%, 4%  maybe 10%? (not 20%) • desire? 8%, 8%  maybe 10%? (not 40%) • attraction? males: 2.8% females: 1.4 %