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PSY 301
INTRODUCTION to PSYCHOPATHOLOGY
Dr. İlkiz Altınoğlu Dikmeer
Fall 2014
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PowerPoint  Lecture Notes Presentation
Chapter 10
Substance Use Disorders
Abnormal Psychology, Twelfth Edition
by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.
Chapter Outline
• Chapter 10: Substance Use Disorders
I. Clinical Descriptions, Prevalence, and
Effects of Substance Use Disorders
II. Etiology of Substance Use Disorders
III. Treatment of Substance Use Disorders
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Table 10.1: Percentage of U.S. Population Reporting Drug Use
in Past Month (2010)
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Substance Use Disorders
• DSM-IV-TR pathological use of substances divided into two
categories:
– Substance dependence (addiction)
Occupational or social problems, much time trying to obtain substance, continued use
despite problems, etc. Involves either tolerance or withdrawal
– Substance abuse (Maladaptive use of substance)
No physiological dependence
• DSM-5 has one category:
– Substance use disorder
– Categorize by specific substance:
•
•
•
•
•
•
•
•
•
•
Alcohol
Amphetamine
Cannabis
Cocaine
Hallucinogen
Inhalant
Opioid
Phencyclidine
Sedative/hypnotic/anxiolytic
Tobacco
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Addiction
• Severe substance use disorder
– Having four more severe symptoms, such as:
• Tolerance : Greater amounts required to produce desired effect
• Withdrawal: Negative physical and psychological effects from
stopping or reducing usage
• Using more than intended amounts
• Trying unsuccessfully to stop
• Having physical or psychological problems made worse by drug
• Experience problematic relationships
– With physiological dependence:
• Presence of either tolerance or withdrawal
– Without physiological dependence:
• Absence of either tolerance or withdrawal
• Tolerance
– Greater amounts required to produce desired effect
– Results from changes in the number or sensitivity of
GABA / glutomate receptors
• Withdrawal
– Negative physical and psychological effects from
stopping or reducing usage e.g./ Restlessness, anxiety,
cramps, twitching or pain in muscles
– Results from increase of activation of neuroal pathways
to compensate for drug’s inhibitoru effects in the
brain.
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Proposed DSM-5 Criteria for
Substance Use Disorder
Problematic pattern of use that impairs functioning.
Two or more symptoms within a 1 year period:
• Failure to meet obligations
• Repeated use in situations where it is physically dangerous
• Repeated relationship problems
• Continued use despite problems caused by the substance
• Tolerance
• Withdrawal
• Substance taken for a longer time or in greater amounts than intended
• Efforts to reduce or control use do not work
• Much time spent trying to obtain the substance
• Social, hobbies, or work activities given up or reduced
• Continued use despite knowing problems caused by substance
• Craving to use the substance is strong
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Alcohol Use Disorder
• Alcoholic
– Physiologically dependent or heavy user
• Delirium tremens (DTs)
– Can occur when blood alcohol levels drop suddenly
– Results in:
• Deliriousness
• Tremulousness
• Hallucinations
– Primarily visual; may be tactile
• Polydrug abuse
– Many alcohol users abuse multiple substances
• e.g., cigarettes, cocaine, marijuana
• 85% of alcohol abusers are smokers
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Prevalence of Alcohol Abuse
• Lifetime prevalence:
– Abuse – 17%
– Dependence – 12%
• Binge drinking
– 5 drinks in short period (e.g., within an hour)
– 43.5% prevalence among college students
• Heavy use drinking
– 5 drinks, 5 or more times in a 30-day period
• 16% prevalence among college students
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Prevalence of Alcohol Abuse
• White and Hispanic adolescents and adults more likely to
binge drink than African Americans
• Binge and heavy use drinking lowest among Asian
Americans
• Alcohol dependence highest among Native Americans and
Hispanics
• 21.3% of those with alcohol abuse or dependence also have
at least 1 mental disorder
– e.g. personality disorders, mood or anxiety disorders, or
schizophrenia
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Short-term Effects of Alcohol
• Enters the bloodstream quickly through small intestine
– Metabolized by the liver slowly at 1 ounce (3 mg) of 100 proof per
hour (%50)
• Effects vary by concentration
– Concentration varies by gender, height, weight, liver efficiency, food
in stomach
• Size of drink defined by alcohol content
– 12 oz. glass of beer, 5 oz. glass of wine, and 1.5 oz. of hard liquor are equal
in alcohol content
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Short-term Effects of Alcohol
• Interacts with several neural systems
– Stimulates GABA receptors
• Reduces tension
– Increases dopamine and serotonin
• Produces pleasurable effects
– Inhibits glutamate receptors
• Produces cognitive difficulties (e.g., slowed thinking, memory loss)
• Effect of ingesting large amounts
– Significant motor impairment
– Poor decision making
– Poor awareness of errors made
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Long-term Effects of Alcohol
•
•
Malnutrition
– Calories from alcohol lack nutrients
– Alcohol interferes with digestion and
absorption of vitamins from food
– Deficiency of B-complex vitamins causes
Amnestic syndrome
• Severe loss of memory for both longand-short-term information
Cirrhosis of the liver
– Liver cells engorged with fat and protein,
impeding functioning
– Cells die, triggering scar tissue which
obstructs blood flow
– Liver disease and cirrhosis rank 12th in
U.S. causes of death.
•
Damage to endocrine glands and pancreas
•
Heart failure
•
Erectile dysfunction
•
Hypertension
•
Stroke
•
Capillary hemorrhages
– Facial swelling and redness, especially
in nose
•
Destruction of brain cells
– Especially areas important to memory
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Fetal Alcohol Syndrome
• Heavy alcohol intake during pregnancy
– Leading cause of mental retardation
– Fetal growth slowed
– Cranial, facial and limb anomalies occur
• Total abstinence by pregnant women recommended
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Tobacco Use Disorder
• Nicotine
– Addicting agent of tobacco
– Stimulates dopamine neurons in mesolimbic area
• Involved in reinforcing effect
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Prevalence and Health Consequences
• About 440,000 Americans die prematurely each year
• Cigarettes kill 1,100 people every day
– 1 of 6 deaths related to tobacco use
• Lung cancer is most common cancer
– 87% caused by smoking
• Cigarettes also cause or exacerbate:
– Emphysema, cancers of larynx, esophagus, pancreas, bladder,
cervix, stomach, cardiovascular disease
– Sudden infant death syndrome and pregnancy complications
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Prevalence and Health Consequences
• More prevalent among White and Hispanic youth than African
Americans
– African Americans less likely to quit and more likely to get lung cancer
• Metabolize nicotine more slowly
• Smoke more menthol cigarettes, which is inhaled more deeply and longer
• More prevalent among men than women
– Exception: 12-to 17-year-olds
• Secondhand smoke (ETS, environmental tobacco smoke)
– Higher levels of ammonia, carbon monoxide nicotine and tar
– Causes 40,000 deaths per year in U.S.
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Marijuana
• Drug derived from dried and ground leaves and
stems of the female hemp plant (Cannibis sativa)
• Hashish
– Stronger than marijuana
– Produced by drying the resin exudate of the tops of
plants
• In DSM-5, called Cannabis use disorder
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Marijuana: Prevalence
• Most frequently used illicit drug in U.S.
– 17,000,000 reported using it in 2010
• Greater use by men than women
• Use more common in European- and Hispanic Americans
than in African- and Asian-Americans, and Hispanics
• Heavier use in US than in Europe, Africa, or Canada
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Figure 10.3: Trends in Drug use Among Young People
Ages 18-25
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Effects of Marijuana
•
•
Major active ingredient
– THC (delta-9-tetrahydrocannabinol)
Psychological
– Feelings of relaxation and sociability
– Rapid shifts of emotion
– Interferes with attention, memory, and thinking
• Decline in IQ over time
– Heavy doses can induce hallucinations and panic
– Difficult to regulate dosage
• Effects take 30 minutes to appear
• Smoke more than intended waiting for
effects
– Interfere with cognitive functioning
• Impairs memory, complex motor skills
•
Physiological
– Bloodshot and itchy eyes
– Dry mouth and throat
– Increased appetite
– Reduced pressure within the eye
– Increased BP
– Damage to lung structure and
function in long-term users
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Marijuana and the Brain
 Two
cannabinoid brain receptors
– CB1 and CB2
– High concentration in hippocampus
• Increased blood flow to emotion regions
– Amygdala and anterior cingulate
• Habitual use leads to tolerance
– Withdrawal symptoms also observed
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Therapeutic Effects of Marijuana
• Reduces nausea and loss of appetite caused by
chemotherapy
• Relieves discomfort of AIDS, chronic pain
• Supreme Court rulings:
– Federal law prohibits dispensing marijuana for medicinal
purposes
– Medical use can be prohibited by federal government
even if states approve
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Opiates
• Group of addictive sedatives that in moderate doses relieve pain and
induce sleep
–
–
–
–
Opium
Morphine
Heroin
Codeine
• Synthetic sedatives
– Separate category from DSM-5 sedative/hypnotic/anxiolytic use disorder
• Opiates legally prescribed as pain medications include:
– Hydrocodone combined with other substances yields Vicodin, Zydone, and Lortab
– Oxycodone the basis for OxyContin, Percodan, and Tylox
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Prevalence of Opiate Use
• Heroin
– Estimated 1,000,000 individuals addicted to heroin in U.S.
– Accounted for 62 to 82% of drug-related hospital admissions in 2003
 5 million pain meds users
– OxyContin prescriptions jumped 1800% between 1996 and 2000
– Hydrocodone use increased from 4.5 to 5.7 million users
– Oxycodone abuse increased 43% in just 1 year (1997 to 1998)
– Rates of abuse of pain meds has remained stable since 2002
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Psychological and Physical Effects of Opiates
• Produce euphoria, drowsiness, and lack of coordination
– Loss of inhibition, increased self-confidence
– Severe letdown after about 4 to 6 hours
• Heroin and OxyContin
– Rush
• Intense feelings of warmth and ecstasy following injection
• Stimulate receptors of the body’s opioid system
– Stimulate nucleus accumbens
• Tolerance develops and withdrawal occurs
– Muscle soreness and twitching, tearfulness, yawning
– Become more severe and also include cramps, chills/sweating, increase in HR
and BP, insomnia, and vomiting
• Heroin withdrawal begins w/in 8 hrs of the last injection and lasts about 72 hours,
diminish gradually over a 5 to10-day period
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Psychological and Physical Effects of Opiates
• 29 year follow-up of 500 heroin addicts
– 28% dead by age 40
• Half by suicide, homicide, or accident
• One-third by overdose
• Many users resort to illegal activities to obtain money for
drugs
– Theft, prostitution, dealing drugs
• Exposure to infectious diseases via shared needles
– e.g. HIV
– Evidence suggests that free needles reduce infectious diseases
associated with IV drug use
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Figure 10.4: ER Visits for
Hydrocodone and Oxycodone ODs
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Stimulants: Amphetamines
• Increase alertness and motor activity; reduce fatigue
• Amphetamines
– Synthetic stimulants
• Benzedrine, Dexedrine, Methedrine
– Trigger release of and block reuptake of norepinephrine and dopamine
– Produce high levels of energy, sleeplessness
– Reduce appetite, increase HR, constrict blood vessels in skin and mucous
membranes
– High doses can lead to:
• Nervousness, agitation, irritability, confusion, paranoia, hostility
– Tolerance can develop after only 6 days’ use
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Stimulants: Methamphetamine
• Methamphetamine (aka crystal
meth)
– Amphetamine derivative
– Can be taken orally, intravenously,
or intranasally (snorting)
• Chronic use damages brain
– Impacts dopamine and serotonin
systems
– Reduction in hippocampus volume
(yellow bars vs. non-users (blue
bars) in figure 10.5, at right)
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Stimulants: Cocaine
•
Crack
– Form of cocaine that quickly become popular in the ’80s
– Rock crystal that is heated, melted, and smoked
– Cheaper than cocaine
•
Alkaloid obtained from coca leaves
–
–
–
–
•
•
Reduces pain
Produces euphoria
Heightens sexual desire
Increases self-confidence and indefatigability
Blocks reuptake of dopamine in mesolimbic areas of brain
Overdose:
– Chills, nausea, insomnia, paranoia, hallucinations; possibly heart attack and death
•
Not all users develop tolerance
– Some become more sensitive
•
•
May increase risk of OD
Cocaine use declined between 2002 and 2009, dropping to 1.4% from 2%
–
Crack use is also declining
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Hallucinogens, Ecstasy, and PCP
•
•
•
LSD
– d-lysergic acid diethylamide
•
•
Hallucinogen effects include:
– Colorful visual hallucinations
– Psychedelic trip: expansion of
consciousness
Only 1-2% regular users
– Active ingredient of peyote
•
Psilocybin
– Extracted from mushroom psilocybe
mexicana
•
Ecstasy (MDMA)
– Methylenedioxymethamphetamine
– Increase feelings of intimacy and enhances
mood
– Chemically similar to mescaline and
amphetamines
– Acts on serotonin
– Improves interpersonal relations
– Its use peaked in 2001, with 1.8 million
users; may be rising again
– African Americans less likely to use
than others
•
Other hallucinogens:
Mescaline
Flashbacks
– Hallucinogen persisting perception
disorder (HPPD)
• Most common during stress
•
PCP (phencyclidine)
– Angel dust
– Animal tranquilizer
– Causes severe paranoia and violence
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Figure 10.6:
Process of Becoming a Drug Abuser
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Etiology of Substance-Use Disorders:
Developmental Approach

Two paths to alcohol abuse (Boys more likely to be in the first group,
girls in the second group)
1. First group began drinking in early adolescence, increased
drinking throughout high school
2. Second group drank lesser amounts in early adolescence,
increased drinking in middle school and again in high school
•
Developmental studies do not account for all cases
–
Not an inevitable progression through stages
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Etiology of Substance-Related Disorders:
Genetic Factors
• Relatives and children of problem drinkers have higher-than-expected rates of
alcohol abuse or dependence
• Greater concordance in MZ than DZ twins
• Genetic and shared environmental risk factors for illicit drug abuse and
dependence appear to be nonspecific
• Ability to tolerate large quantities of alcohol may be an inherited diathesis
– Asians have low rates of alcohol abuse
• Deficient enzymes (ADH or alcohol dehydrogenases)
• Genes and smoking
– People with SLC6AS less likely to smoke and more likely to quit
– Smokers with defect in CYP2A6 gene less likely to become dependent
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Etiology of Substance-Related Disorders:
Neurobiological Factors
•
Nearly all drugs, including alcohol, stimulate the dopamine system in the brain, particularly the
mesolimbic pathway
–
–
–
Produce rewarding or pleasurable feelings
Some evidence that people dependent on drugs or alcohol have a deficiency in the dopamine receptor DRD2
Vulnerability model vs. Toxic effect model
•
•
People take drugs to avoid the bad feelings associated with withdrawal
–
•
Explains frequency of relapse
Incentive-sensitization theory
–
–
–
•
Vulnerability in the dopamine system leads to substance use or substance use leads to dopamine system problems
Distinguish Wanting (craving for drug) from Liking (pleasure obtained by taking the drug)
Dopamine system becomes sensitive to the drug and the cues associated with drug (e.g., needles, rolling papers, etc.)
Sensitivity to cues induces and strengthens wanting
Brain imaging studies show that cues for a drug (needle or a cigarette) activate the reward and
pleasure areas of the brain involved in drug use
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Figure 10.7: Reward Pathways in Brain Affected by Different
Drugs
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Etiology of Substance-Use Disorders: Psychological
factors
• Mood alteration
– Tension reduction may be due to “alcohol myopia”
• User focuses reduced cognitive capacity on immediate distractions
• Less attention focused on tension-producing thoughts
– Effect similar for smoking
– However, alcohol and nicotine may increase tension when no
distractions are present
• Crying in one’s beer
• Expectancies about drug effects
– People who expect alcohol to reduce stress and anxiety are most likely to drink
– Drinking and positive expectancies influence each other positively
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Etiology of Substance-Use Disorders: Personality
• Personality factors that predict onset of substance-related disorders:
– Negative emotionality or negative affect
– Desire for increased arousal and positive affect
– Low constraint
• Harm avoidance, conservative moral values, and cautious behavior
• Kindergarten children who were rated high in anxiety and novelty
seeking more likely to get drunk, smoke, and use drugs in adolescence
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Etiology of Substance-Use Disorders: Sociocultural
Factors
• Alcohol is the most common abused substance worldwide
– Highest consumption in France, Spain, and Italy where consumption is widely
accepted
• Men consume more alcohol than women but differences vary by
country
– Israel
• Men drank 3x as much as women
– Netherlands
• Men drank 1½x as much as women
• Availability
– Usage is higher when alcohol and drugs are easily available
• In 2003, drug use among youths who had been approached by drug dealers was 35
percent, compared to just under 7 percent among youths who had not been approached
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Etiology of Substance-Use Disorders: Sociocultural
Factors
• Family factors
– Parental alcohol use
– Marital discord, psychiatric or legal problems in the family linked to
substance use
– Lack of emotional support from parents increases use of cigarettes,
marijuana, and alcohol
– Lack of parental monitoring linked to higher drug usage
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Etiology of Substance-Related Disorders: Sociocultural
Factors
• Social network
– Social influence or social selection?
– Bullers et al. (2001) found evidence for both
• Having peers who drink influences drinking behavior (social influence) but
individuals also choose friends with drinking patterns similar to their own
(social selection)
• Advertising and media
– Countries that ban ads have 16% less consumption than those that
don’t
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Treatment of Substance Use Disorders:
Alcohol Use Disorders
• In 2009, 1.5 million people over the age of 12 received treatment for alcohol abuse or
dependence
– Over 17 million people over the age of 12 were in need of treatment for alcohol or drug
problems, but did not get it
– Only 1 in 4 who are physiologically dependent ever get treatment
• Inpatient hospital treatment
– Detoxification
• Withdrawal from alcohol under medical supervision
• The therapeutic results of hospital treatment are not superior to those of outpatient treatment
• May be necessary for those without social support or with other serious psychological problems
• Alcoholics Anonymous (AA)
–
–
–
–
Largest self-help group for problem drinkers
Regular meetings provide support, understanding, and acceptance
Promotes complete abstinence
Although some studies have shown AA participation predicts better outcome, recent studies
suggest AA no more effective©than
other
forms
ofInc.
therapy
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& Sons,
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Table 10.2:
The 12 Steps of AA
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Treatment of Substance Use Disorders:
Alcohol Use Disorders
• Cognitive and Behavioral Treatments
– Contingency-Management Therapy
• Patient and family reinforce behaviors inconsistent with drinking
– e.g., avoiding places associated with drinking
• Teach problem drinker how to deal with uncomfortable situations
– e.g., refusing the offer of a drink
– Relapse prevention
• Strategies to prevent relapse
• Motivational interventions
– Designed to curb heavy drinking in college
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Treatment of Substance Use Disorders:
Alcohol Use Disorders
• Controlled drinking
– Belief that problem drinkers can consume alcohol in moderation
– Avoid total abstinence and inebriation
– Guided self-change
• Medications
– Antabuse (disulfiram)
• Produces nausea and vomiting if alcohol is consumed
– Other medications include naltrexone, naloxone, and acamprosate
• Most effective when combined with CBT
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Treatment of Substance Use Disorders:
Nicotine Dependence
• Peer behavior important
– If others in social network stop smoking, increases likelihood that individual will
also stop
• Physician’s advice
– By age 65, most smokers have quit
• Scheduled smoking
– Reduce nicotine intake gradually over a few weeks
• Nicotine replacement treatments
– Gum, patches, or inhalers
– Reduce craving for nicotine
– Combining patch with antidepressants (Wellbutrin) improved success rate
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Treatment of Drug Use Disorders
• Detoxification central to treatment
• Psychological treatments
– Desipramine and CBT showed effectiveness for cocaine use
• CBT especially helpful for users with high dependence levels
– Contingency management
• Vouchers that can be traded for desirable goods are given to users who abstain
– Motivational interviewing or enhancement therapy
• CBT plus solution focus therapy effective for alcohol and drug use
– Self-help residential homes
• Non-drug environment
• Group therapy
• Guidance and support from former users
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Treatment of Drug Use Disorders:
Drug Replacement Treatments and Medications
• Heroin substitutes
– Synthetic narcotics
• Methadone, levomethadyl acetate, bupreophine
• Used to wean heroin users from dependence
• Opiate antagonists
– Naltrexone
• Prevents feeling high
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Prevention of Substance-Use Disorders
• Often aimed at adolescents
• Utilize some or all of the following elements:
–
–
–
–
–
–
–
–
–
–
Enhancing self-esteem
Social skills training
Peer pressure resistance training
Parental involvement in school programs
Warning labels on alcohol bottles
Education regarding alcohol impairment
Testing for drugs and alcohol at school or work
Correction of beliefs and expectations
Inoculation against mass media messages
Peer leadership
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