Download Chapter Overview

CHAPTER 10
SUBSTANCE-RELATED, ADDICTIVE, AND
IMPULSE-CONTROL DISORDERS
CHAPTER OVERVIEW
This chapter outlines the major features of substance-related and addictive disorders, with
discussions of substance use, intoxication, abuse, and dependence, including categories regarding
depressants (alcohol, barbiturates, and benzodiazepines), stimulants (amphetamines, cocaine,
tobacco, and caffeine), opioids (heroin, codeine, and morphine), cannabis-related drugs
(marijuana), hallucinogens (LSD and other substances), and other drugs of abuse (inhalants and
steroids). In addition, patterns of drug use, etiological factors, mechanisms of action, and
treatments are discussed within an integrative bio-psycho-social framework. The chapter
concludes with a review and discussion of gambling disorder and impulse-control disorders
(intermittent explosive disorder, kleptomania, and pyromania).
LEARNING OBJECTIVES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Describe the nature of substance-related and addictive disorders.
Describe the physiological and psychological effects of depressants.
Describe the physiological and psychological effects of stimulants.
Describe the physiological and psychological effects of opiates.
Describe the physiological and psychological effects of cannabis.
Describe the physiological and psychological effects of hallucinogenics.
Describe the physiological and psychological effects of other drugs, including
inhalants, steroids, and designer drugs.
Describe the physiological and psychological processes that lead to substance
dependence.
Identify the psychological and medical treatments available for substance-related
disorders.
Describe the psychological and physiological processes that lead to gambling
disorders.
Describe what constitutes an impulse-control disorder, and identify the conditions
listed in this category in DSM-5.
CHAPTER OUTLINE
PERSPECTIVES ON SUBSTANCE-RELATED AND ADDICTIVE DISORDERS
Levels of Involvement
151
Diagnostic Issues
DEPRESSANTS
Alcohol-Related Disorders
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
STIMULANTS
Stimulant-Related Disorders
Tobacco-Related Disorders
Caffeine-Related Disorders
OPIOIDS
CANNABIS-RELATED DISORDERS
HALLUCINOGEN-RELATED DISORDERS
OTHER DRUGS OF ABUSE
CAUSES OF SUBSTANCE-RELATED DISORDERS
Biological Dimensions
Psychological Dimensions
Cognitive Dimensions
Social Dimensions
Cultural Dimensions
An Integrative Model
TREATMENT OF SUBSTANCE-RELATED DISORDERS
Biological Treatments
Psychosocial Treatments
Prevention
GAMBLING DISORDER
IMPULSE-CONTROL DISORDERS
Intermittent Explosive Disorder
Kleptomania
Pyromania
152
DETAILED OUTLINE
Perspectives on Substance-Related Disorders
What are substance-related and addictive disorders?
 In DSM-5, substance-related and addictive disorders include problems with the use of
depressants (alcohol, barbiturates, and benzodiazepines), stimulants (amphetamine, cocaine,
nicotine, and caffeine), opiates (heroin, codeine, and morphine), and hallucinogens (cannabis
and LSD) as well as gambling.
 Specific diagnoses are further categorized as substance intoxication and substance
withdrawal.
 DISCUSSION POINT:
What do you perceive to be the most significant drug problem in your community?
This discussion will bring out students’ beliefs about the dangerousness of drugs, association
with criminal activity, addictive potential, and other factors. Encourage your students to
discuss what influenced their selection.
 Nonmedical drug use in the United States has declined in recent times, although it continues
to cost billions of dollars and seriously impairs the lives of millions of people each year.
Depressants, Stimulants, and Opioids
What are the physiological and psychological effects of depressants?
 Depressants are a group of drugs that decrease central nervous system activity. The primary
effect is to reduce our levels of physiological arousal and help us relax. Included in this
group are alcohol and sedative, hypnotic, and anxiolytic drugs, such as those prescribed for
insomnia.
What are the physiological and psychological effects of stimulants?
 Stimulants, the most commonly consumed psychoactive drugs, include caffeine (in coffee,
chocolate, and many soft drinks), nicotine (in tobacco products such as cigarettes),
amphetamines, and cocaine. In contrast to the depressant drugs, stimulants make us more
alert and energetic.
 DISCUSSION POINT:
Many of the drugs discussed in this chapter have effects similar to the symptoms of
psychological disorders, such as mood swings and paranoia. What does this tell you about
underlying biological or other factors in drug use?
What are the physiological and psychological effects of opiates?
153
 Opiates include opium, morphine, codeine, and heroin; they have a narcotic effect—relieving
pain and inducing sleep. The broader term opioids is used to refer to the family of substances
that includes these opiates and synthetic variations created by chemists (e.g., methadone) and
the similarly acting substances that occur naturally in our brains (enkephalins, betaendorphins, and dynorphins).
Cannabis-Related Disorders
What are the physiological and psychological effects of cannabis?
 Cannabis (marijuana) is the most routinely used illegal substance, with 5% to 15% of people
in western countries reporting regular use. Perhaps more than any other drug, however,
cannabis can produce different reactions in people, including a sense of well-being, mood
swings, and paranoia.
 DISCUSSION POINT:
Why is marijuana the most frequently used illegal drug in society?
 DISCUSSION POINT:
Recently some states have moved to not only decriminalize but actually legalize the
possession and use of small amounts of marijuana. Do you support this movement? Why or
why not? Can you think of some unintended consequences of such policy changes?
Hallucinogen-Related Disorders
What are the physiological and psychological effects of hallucinogenics?
 Hallucinogens essentially change the way the user perceives the world. Sight, sound,
feelings, and even smell are distorted, sometimes in dramatic ways, in a person under the
influence of drugs such as cannabis and LSD.
Other Drugs of Abuse
What are the physiological and psychological effects of other drugs, including inhalants,
steroids, and designer drugs?
 A number of other substances are used by individuals to alter sensory experiences. The high
associated with the use of inhalants resembles that of alcohol intoxication and usually
includes dizziness, slurred speech, incoordination, euphoria, and lethargy. Steroid use differs
from other drug use because the substance does not produce a desirable high but instead is
used to enhance performance and body size. Designer drugs heighten a person’s auditory and
visual perception, as well as the senses of taste and touch.
Causes and Treatment of Substance-Related Disorders
What physiological and psychological processes lead to substance dependence?
154
 Most psychotropic drugs seem to produce positive effects by acting directly or indirectly on
the dopaminergic mesolimbic system (the pleasure pathway). In addition, psychosocial
factors such as expectations, stress, and cultural practices interact with the biological factors
to influence drug use.
What psychological and medical treatments are available for substance-related disorders?
 Substance dependence is treated successfully only in a minority of those affected, and the
best results reflect the motivation of the drug user and a combination of biological and
psychosocial treatments.
 Programs aimed at preventing drug use may have the greatest chance of significantly
affecting the drug problem.
 DISCUSSION POINT:
What are the strengths and limitations of using biological treatments for substance abuse
and dependence?
Gambling Disorder
What psychological and physiological processes lead to a gambling disorder?
 Problem gamblers display the same types of cravings and dependence as persons who have
substance-related disorders.
 Similar brain systems appear to be involved with those addicted to gambling as seen in
persons with substance-related disorders.
 DISCUSSION POINT:
How is pathological gambling similar to, and different from, substance use disorders?
What have we learned from the treatment of substance-related disorders that may be
applied to pathological gambling?
Impulse-Control Disorders
What conditions are listed in DSM-5 as impulse-control disorders?
 In DSM-5, impulse-control disorders include three separate disorders: intermittent explosive
disorder, kleptomania, and pyromania.
KEY TERMS
substance-related and addictive disorders,
367
impulse-control disorders, 367
polysubstance use, 367
155
psychoactive substance, 369
substance use, 369
substance intoxication, 369
substance abuse, 369
substance dependence, 370
tolerance, 370
withdrawal, 370
depressants, 371
stimulants, 371
opiates, 371
hallucinogens, 371
other drugs of abuse, 371
gambling disorder, 371
alcohol-related disorders, 372
alcohol, 372
withdrawal delirium (delirium tremens/DTs),
373
Wernicke-Korsakoff syndrome, 373
fetal alcohol syndrome (FAS), 374
alcohol dehydrogenase (ADH), 374
barbiturates, 376
benzodiazepines, 376
sedative-, hypnotic-, and anxiolytic-related
disorders, 377
amphetamine use disorders, 379
cocaine use disorders, 383
tobacco-related disorders, 382
caffeine-related disorders, 383
opioid-related disorders, 383
Cannabis (Cannabis sativa) (marijuana), 385
cannabis use disorders, 385
LSD (d-lysergic acid diethylamide), 386
hallucinogen use disorders, 386
agonist substitution, 396
antagonist drug, 396
nicotine, 396
nicotine patch, 396
controlled drinking, 398
relapse prevention, 399
gambling disorder, 400
intermittent explosive disorder, 401
kleptomania, 402
pyromania, 402
IDEAS FOR INSTRUCTION
1.
Activity: Demonstrate Cigarette Smoking Residue. This exercise can be used to
demonstrate the residue that remains in the body when smoking a cigarette. You will need
two cigarettes and a “smoking apparatus” in this exercise. The apparatus can be borrowed
from a local chapter of the American Cancer Society or American Lung Association, or it
can be built at home. To build the apparatus, you need the following items:
a. A clean, empty, flexible plastic bottle such as a dishwashing soap container with a
top (a transparent bottle would be ideal).
b. Plastic tubing about the size of a cigarette; a cigarette must be able to fit snugly
within the tubing.
c. A small ball of clay, a cotton ball or loose cotton, a book of matches, and two
index cards on which to place cigarette parts and transparent tape.
Make an opening in the bottle cap so the tubing fits snugly. Insert the tubing
through the hole, leaving about an inch extending out of the top. Use the clay to form a
seal where the tube meets the top. Insert loosely packed cotton into the opposite end of the
tubing. Be sure to do this demonstration in a well-ventilated room. The procedure is as
follows:
a. Squeeze air out of the bottle and place cigarette firmly into the end of the tubing.
b. Light the cigarette and begin to slowly compress and release the sides of the bottle.
Continue until the cigarette is almost completely “smoked.”
156
c. Remove the cigarette, cut off the filter, tape it to the index card, and pass it around.
Discuss the residue that remains and the effectiveness of filters.
d. Remove the cotton from the tubing, tape it to the index card, and pass it around.
This represents the residue that is introduced into a smoker’s lungs despite the
presence of a filter.
Clearly instructors should consider institutional regulations regarding a lit cigarette in
the classroom, even for educational purposes, and perhaps get advance authorization
for this activity.
2.
Activity: Should Mandatory Drug Testing Become Part of Campus Life? Mandatory
random drug testing is becoming increasingly routine in large corporations. Yet, whether
such drug testing curbs drug abuse is a matter over which there is still considerable
debate. Mandatory drug testing raises a host of ethical and constitutional issues about
right to privacy. Discuss the issues related to mandatory drug testing and ask students to
consider whether colleges and universities should adopt a regular policy of random drug
testing among their students. What would be the implications of this move for drug use
on college campuses? Would such a policy work to deter drug use? This topic should
result in some lively discussion and debate.
3.
Activity: Student Response to Signs of Addiction in Friends and Family. Ask
students to break up in small groups for this exercise and have each group address how
they would approach a situation where they strongly suspected that either a family
member or close friend was on the road to addiction. Would they be comfortable saying
anything to that person about his or her use of drugs? How would they broach the
subject? What sorts of reactions might they expect in the other person after they
confronted him or her? What steps would they take to help that person? Sample the
responses from different groups, tally them on an overhead or blackboard, and open the
discussion up to an analysis of the assets and liabilities of different proposals.
4.
Video Activity: The Case of Tim and the Problem of Alcohol Dependence. Show the
film segment on Part II of the videotape “Abnormal Psychology: Inside/Out, Video 1,
Vol. 1” that presents an interview with a patient (Tim) who suffers from alcohol
dependence. Ask the students to consider how and why it took the negative consequences
of alcohol abuse to lead Tim to the realization he had a problem with alcohol. What role
did Tim’s family play in perpetuating Tim’s pattern of addiction and what might have
been done to prevent Tim from developing full-blown alcoholism? Finally, what
treatment do the students think would be best for Tim (e.g., controlled drinking or
complete alcohol abstinence)?
5.
Drug Use and Health. Develop a lecture on the National Survey on Drug Use and
Health, sponsored by the Substance Abuse and Mental Health Services Administration
(SAMHSA), which showed that the second most popular category of drug use after
marijuana is the non-medical use of prescription drugs. The growing problem of abuse
and addiction to prescription medications can be described and illustrated. The following
link is to a SAMHSA website with extensive information on prescription drug abuse and
157
relevant links, including a multimedia video segment that you can show in the classroom
(http://captus.samhsa.gov/prevention-practice/targeted-prevention/prescription-drugabuse).
SUPPLEMENTARY READING MATERIAL
Additional Readings:
Clipson, C., & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA:
Houghton Mifflin Company. Chapter 9, Alcohol Dependence: The Web that Denial
Weaves.
Donovan, D. M., & Marlatt, G. A. (2007). Assessment of addictive behaviors (2nd ed.).
New York: Guilford.
Ellickson, P. L., & Bell, R. M. (1990). Drug prevention in junior high: A multi-site
longitudinal test. Science, 247, 1299-1305.
Galanter, M. (1996). Recent developments in alcoholism, Volume 13: Alcohol and
violence: Epidemiology, neurobiology, psychology, and family issues. New York:
Plenum.
Galanter, M., & Kleber, H. D. (2008). The American Psychiatric Publishing textbook of
substance abuse treatment (4th ed.). Washington, DC: American Psychiatric Pub.
Gallant, D. M. (1987). Alcoholism: A guide to diagnosis, intervention and treatment. New
York: W. W. Norton.
Glantz, M., & Pickens, R. (Eds.) (1991). Vulnerability to drug abuse. Washington, DC:
American Psychological Association.
Goldstein, A. (2001). Addiction from biology to drug policy (2nd ed.). Oxford: Oxford
University Press.
Gomberg, E., & Nirenberg, T. D. (Eds.) (1994). Women and substance abuse. Norwood,
NJ: Ablex Press.
Gootenberg, P. (1999). Cocaine: Global histories. New York: Routledge.
Gorski, T., & Miller, M. (1986). Staying sober: A guide for relapse prevention.
Independence, MO: Independence Press.
Heather, N., Miller, W. R., & Greeley, J. (Eds.) (1994). Self-control and addictive
behaviors. New York: Pergamon.
158
Hester, R. K., & Miller, W. R. (2003). Handbook of alcoholism treatment approaches:
Effective alternatives (3rd ed.). Boston: Allyn and Bacon.
Marlatt, G. A., & Donovan, D. M. (2008). Relapse prevention: Maintenance strategies in
the treatment of addictive behaviors (2nd ed.). New York: Guilford.
McCrady, B. S., & Miller, W. R. (Eds.) (1993). Research on Alcoholics Anonymous:
Opportunities and alternatives. New Brunswick, NJ: Alcohol Research Documentation.
Meyers, R. J., & Smith, J. D. (1995). Clinical guide to alcohol treatment: The community
reinforcement approach. New York: Guilford.
Miller, W. R., & Hester, R. K. (1986). Inpatient alcoholism treatment: Who benefits?
American Psychologist, 41, 794–805.
Nathan, P. E. (1993). Alcoholism: Psychopathology, etiology, and treatment. In P. B.
Sutker & H. E. Adams (Eds.) Comprehensive handbook of psychopathology. New York:
Plenum Press, pp. 451–476.
Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices
and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 9, SubstanceRelated Disorders.
Stoil, M. J., & Hill, G. (1996). Preventing substance abuse: Interventions that work. New
York: Plenum.
Streissguth, A. (1999). Fetal alcohol syndrome: A guide for families and communities.
New York: Brooks Cole.
Tucker, J. A., Donovan, D. M., & Marlatt, G. A. (Eds.) (2001). Changing addictive
behavior: Bridging clinical and public health strategies. New York: Guilford.
Walters, S., & Rotgers, F. (2012). Treating substance abuse: Theory and technique (3rd
ed.). New York: Guilford Press.
SUGGESTED VIDEOS
Abnormal Psychology Inside/Out. (Available through your International Thomson
Learning representative). This video presents an interview with Tim, a patient who suffers from
alcohol abuse/dependence. Tim describes how he first came to realize he had a problem with
alcohol when he was arrested for assaulting others, experienced family problems, and
accumulated DWIs. (13 min)
Clean and sober. This film provides a nice portrayal of Alcoholics Anonymous,
alcoholism, and cocaine addiction.
159
Drugs of Abuse. (Insight Media). In this DVD, doctors and clinicians join individuals in
recovery to discuss the symptoms and consequences of drug abuse, the neurobiology of
addiction, substance abuse treatment, and life in recovery. The program examines the
progression from drug abuse to recovery management, looking at such drugs as alcohol, nicotine,
marijuana, heroin, cocaine, inhalants, and prescription drugs. (90 min)
Introduction to Structured Relapse Prevention: An Integrative Approach to Working With
Alcohol and Other Drug Problems (Insight Media). This program presents an overview of
Structured Relapse Prevention, an integrated therapeutic methodology that includes aspects of
motivational interviewing, cognitive-behavioral treatment, and coping skills. (90 min)
Leaving Las Vegas. This film depicts in graphic visual imagery the struggle of a man
suffering from severe alcoholism as he gives up on life and spirals into controlled chaos toward
his own death. Features Nicolas Cage and Elisabeth Shue, both of whom won Oscars for their
leading roles.
The lost weekend. This film depicts four days in the life of an alcoholic, failed writer. It
won Oscars for Best Picture, Actor, Director, and Writing.
Ray. This film shows rhythm & blues icon Ray Charles’s struggle with heroin, including
his eventual recovery. Features Jamie Foxx, who won an Oscar for his leading role.
Sweet nothing. This film depicts the nature of crack addiction and is based on a true
story.
Trainspotting. This film depicts the heroin scene in Edinburgh and presents accurate
depictions of cold turkey heroin withdrawal symptoms.
Walk the line. This film shows rock icon Johnny Cash’s struggle with alcohol and drugs,
including his eventual recovery. Features Joaquin Phoenix and Reese Witherspoon, who won an
Oscar for her leading role.
When a man loves a woman. This film shows the struggles of a woman and her family as
she struggles to overcome alcohol addiction. Inpatient treatment as well as marital therapy,
Alcoholics Anonymous, and Al-Anon are used as part of the recovery plan. Features Meg Ryan
and Andy Garcia.
ONLINE RESOURCES
Alcoholics Anonymous
http://www.alcoholics-anonymous.org/
The official webpage for Alcoholics Anonymous; information includes the “Twelve Steps
to Recovery.”
160
Brief Addiction Science Information Source (BASIS)
http://basisonline.org
This site provides brief overviews, in lay language, of recent studies in substance abuse
and dependence. Students may sign up for a periodic newsletter on substance misuse, as well as
one on problem gambling.
Center for Education and Drug Abuse Research (CEDAR)
http://cedar.pharmacy.pitt.edu
CEDAR serves to elucidate the factors contributing to the variation in the liability of drug
abuse and determine the developmental pathways culminating in drug abuse outcome, normal
outcome, and psychiatric/behavioral disorder outcome. CEDAR is based at the University of
Pittsburgh.
Cocaine Anonymous Home Page
http://www.ca.org/
This group uses the Twelve Steps program to help recovering cocaine addicts. It includes
phone numbers for local chapters as well as links.
Montana Methamphetamine Project
http://www.montanameth.org/
This is the site of a major prevention project for methamphetamine use in Montana. The
site contains media images, commercials, and other depictions intended to prevent youth from
trying the stimulant drug.
National Council on Problem Gambling
http://www.ncpgambling.org/
This website is a great resource about issues related to problem gambling and its
treatment.
National Institute on Drug Abuse (NIDA)
http://www.nida.nih.gov/
This site provides a wealth of information about drug abuse, drug treatment, and current
research, including informative fact sheets about most major drugs of abuse.
Substance Abuse & Mental Health Services Administration (SAMHSA)
http://www.samhsa.gov
At this site, which features information for professionals as well as consumers of services,
substance abuse topics are arranged in terms of specific areas of impact (e.g., homelessness,
children and families). Statistics related to drug use and abuse are available as well.
Web of Addictions
http://www.well.com/user/woa/
This website provides fact sheets on drugs and drug abuse, links to other Internet
resources, and places to get help with addictions.
161
COPYRIGHT ©2016 Cengage Learning
WARNING SIGNS OF
AN ALCOHOL-RELATED DISORDER
 Drinking heavily after a disappointment, a quarrel, or when a boss is difficult
 Drinking more heavily when experiencing difficulties or feeling under pressure
 Ability to “handle” more liquor than when you first started drinking
 Failure to remember events occurring during a previous drinking episode
 Drinking extra amounts of alcohol secretively during social gatherings
 Feeling uncomfortable during occasions when alcohol is not available
 Feeling guilty about drinking
 Feeling irritated when family or friends discuss your drinking
 An increase in the frequency of memory blackouts
 Wishing to continue drinking after others say “enough is enough”
 Having a reason for the occasions when you drink heavily
 Feeling regret while sober for things said or done while drinking
 Attempts to switch brands or to follow different plans to control drinking
 Failure to keep promises about cutting down on drinking
 Failed attempts to control drinking by making a change in jobs or moving
 Avoidance of family or close friends while drinking
 Having an increasing number of financial and work problems
 Feeling as though more people are treating you unfairly without good reason
 Eating very little or irregularly while drinking
 Drinking in the morning to alleviate the shakes
 Noticing that it is difficult to drink as much as previously
 Staying drunk for several days at a time
 Feeling depressed and wondering whether life is worth living
 Hearing or seeing things that aren’t there following a period of drinking
 Experiencing extreme fear after heavy drinking
162
COPYRIGHT ©2016 Cengage Learning
WARNING SIGNS OF A SUBSTANCE-RELATED OR
ADDICTIVE DISORDER
 Losing time from work due to drinking/drugs
 Drinking/using drugs makes home life unhappy
 Drinking/using drugs because of shyness around other people
 Drinking/using drugs negatively affects your reputation
 Feeling remorse after drinking/using drugs
 Experiencing financial difficulties as a result of drinking/drugs
 Decreased ambition since drinking/using drugs
 Craving a drink/drugs at a definite time daily
 Wanting a drink/drugs the next morning
 Experiencing sleeping problems related to drinking/using drugs
 Decreased efficiency since drinking/using drugs
 Drinking/using drugs is jeopardizing one’s job or business
 Drinking/using drugs to escape from worries or troubles
 Drinking/using drugs while alone
 Experiencing a complete loss of memory as a result of drinking/using drugs
 Drinking/using drugs to build up self-confidence
 Hospitalization or medical care due to drinking/drug use
163
COPYRIGHT ©2016 Cengage Learning
WARNING SIGNS OF GAMBLING DISORDER
 Preoccupation with gambling (e.g., thinking of ways to get money to
gamble)
 Lost time from work or family due to gambling
 Neglect responsibilities to yourself or family in order to gamble
 Pawned or sold personal possessions for gambling money
 Borrowed money under false pretences to gamble
 Need to gamble with increasing amounts of money to achieve excitement
 Repeated unsuccessful efforts to control, cut back, or stop gambling
 Restless or irritable when attempting to cut down or stop gambling
 Gamble as a way of escaping from problems or to relieve negative feelings
 After losing money gambling, returning another day to “get even”
 Lying to conceal the extent of involvement with gambling
 Committing illegal acts (e.g., forgery, fraud, theft) to finance gambling
 Jeopardizing a significant relationship, job, or educational/career opportunity
because of gambling
 Relying on others to provide money to relieve a desperate financial situation
caused by gambling
 Feeling hopeless, depressed, or suicidal due to gambling
.
164