Substance-Related Disorders

1. Substance-Related Disorders

2. Substance-Related Disorders • Substance dependence • Substance abuse • Substance intoxication • Substance withdrawal • alcohol • amphetamines • caffeine • cannabis • cocaine • hallucinogens • inhalants • nicotine • opioids • phencyclidine • sedative/hypnotic/anxiolytic

3. Criteria for Substance Dependence A maladaptive pattern of substance abuse, leading to impairment or distress as manifested by 3 or more symptoms within a 12-mo. period • tolerance • a need for markedly increased amount of substance • markedly diminished effect with same amount of substance • withdrawal • characteristic withdrawal syndrome for substance • taking same substance to relieve withdrawal symptoms • larger amounts over longer period than intended • persistent desire or unsuccessful efforts to cut down • time spent in acquiring, using, & recovering • important activities given up/reduced • continued use despite persistent physical or psychological • problem caused by substance

4. Substance Dependence Specifyers: • with physiological dependence • (evidence of tolerance or withdrawal) • without physiological dependence • (no evidence of tolerance or withdrawal)

5. Cocaine and Physiological Brain Changes • use dopamine agonists that flood synapses with DA • and overshadow normal rewarding activities • attempt to restore homeostasis • downregulating DA receptors on post-synaptic neurons • upregulating MAO • lower levels of DA in synapses during “non-use” periods • craving for more of the dopamine-agonist substance

6. Criteria for Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following: • recurrent substance use resulting in failure to fulfill major role • obligations at work, school, or home • recurrent substance use in which it is physically hazardous • recurrent substance-related legal problems • continued substance use despite having persistent interpersonal • problems caused by substance Symptoms have never met criteria for Substance dependence for this drug

7. Criteria for Substance Intoxication • The development of a reversible substance-specific syndrome due • to recent ingestion of (or exposure to) a substance. B. Clinically significant maladaptive behavioral or psychological changes due to effect of substance on central nervous system • impaired judgment • impaired social/occupational • functioning • belligerence • mood lability • cognitive impairment C. Symptoms are not due to a medical condition or mental disorder

8. Alcohol-Related Disorders

9. Criteria for Alcohol Intoxication A. Recurrent ingestion of alcohol B. Significant maladaptive behavioral or psychological changes • inappropriate sexual behavior • inappropriate aggression • mood lability • impaired judgment C. One or more of the following signs shortly after ingestion: • slurred speech • incoordination • unsteady gait • nystagmus (involuntary eye movements) • impairment in attention or memory • stupor or coma D. The symptoms are not better accounted for by a medical condition or by another mental disorder.

10. Criteria for Alcohol Withdrawal A. Cessation of alcohol use that has been heavy and prolonged. B. Two or more of the following developing after cessation: • autonomic hyperactivity (e.g., sweating, pulse over 100) • increased hand tremor • insomnia • nausea or vomiting • transient hallucinations or illusions • psychomotor agitation • anxiety • grand mal seizures C. Symptoms cause significant distress or impairment in social/ occupational functioning D. The symptoms are not better accounted for by a medical condition or by another mental disorder.

11. Bad Stuff Associated with Alcohol Abuse Short-term: • 25,000 highway deaths per year • industrial accidents, public transportation accidents • over one-half of all murders involve alcohol • child and spouse abuse • one-half of all suicides involve alcohol • fetal alcohol syndrome Long-term: • increased risk of heart disease • increased risk of throat and stomach cancer • cirrhosis of the liver • Korsakov Syndrome (amnestic disorder) • depression • marital breakup • loss of job and school failure

12. Why Do People Drink? (Cooper et al., 1995) • To enhance positive feelings • celebrations, social gatherings • increase arousal, energy, joy • desire for psychomotor activation • associated with extraversion, sensation-seeking • B. To cope with negative feelings • reduce anxiety, depression • avoidance or denial negative life event • forget problems • avoidance of responsibility • associated with neuroticism, low self-esteem

13. Why Do People Drink? Dual-Pronged Method of Action • interacts with mesolimbic dopamine and opioid systems • initial buzz (and psychomotor activation) • feelings of mild euphoria, self-confidence, sociability • interacts with glutamate and GABA systems • decreases glutamate • increases GABA • decreases anxiety and self-consciousness • decreases negative mood and irritability • suppresses CNS activation Note that there is a dose-dependent response to alcohol

14. Is There a Genetic Basis to Alcoholism? • twin studies and adopted away studies • indicate a genetic component • adopted away SOMAs 4 times as likely to be alcoholic • as adopted nonSOMAs • twin studies show inheritance in males • polygenetic

15. Cloninger’s Type I and Type II Alcoholics Type I • later onset • more likely to be triggered by specific event • more environmental influence • equal number of males and females Type II • early onset • physical problems • much larger heritability • associated with antisocial acts • more likely to be aggressive • much more common in males

16. Factors Affecting Alcoholism

17. Social/Cultural Factors Affecting Alcoholism • society’s attitude toward drinking • peer pressure (group ID) • media portrayal • low SES • high availability • high EE in families

18. Psychological Factors Affecting Alcoholism • expectancies • sensation-seeking • anxiety-proneness • lack of other coping mechanisms

19. Biological Factors Affecting Alcoholism • genetic predisposition • low frontal arousal • Aldehyde dehydrogenase (ALDH) deficit • HR reactivity to alcohol • MAO abnormalities

20. Is Alcohol a Disease? Disease model asserts that alcoholism is caused by a physiological defect similar to diabetes. Alternate model characterizes alcoholism as a character flaw • Disadvantages of Disease Model • reduces addict’s accountability • removes incentive to abstain • places addict in victim role • inconsistent with data that say • “controlled” use may be achieved • self-fulfilling prophesy • Advantages of Disease Model • brought problem to public • awareness • got funding to study alcoholism • removes stigma • got treatment developed and • funded

21. Treatment of Alcoholism Biological • detoxification (benzodiazapines) • disulfiram (Antabuse) • Naltrexone • acamprosate (Campral) Psychological • Alcoholics Anonymous • Cognitive Behavioral treatments • Controlled Drinking Social • token economy

22. The COMBINE Study JAMA (2006) Best outcome: Naltrexone plus medical management or 10-20 session CBT plus medical management

23. Questions of the Week: 1. Do you feel that alcoholism is a disease or a failure of will power and self-control? Why? 2. Can alcoholics successfully achieve controlled drinking, or is total abstinence the only option? Justify your answer with information from the readings and lecture. Recommended Movie of the Week: Days of Wine and Roses starring Jack Lemon Lee Remick