Download AP8_Lecture_12 - Forensic Consultation

Substance Use and
Addictive Disorders
Chapter 12
Slides & Handouts by Karen Clay Rhines, Ph.D.
American Public University System
Comer, Abnormal Psychology, 8e
DSM-5 Update
Substance Use Disorders

Many drugs are available in our society

Some are harvested from nature, others
derived from natural substances, and still
others are produced in a laboratory

Some require a physician’s prescription for
legal use; others, like alcohol and nicotine, are
legally available to adults

Still others, like heroin, are illegal under all
circumstances
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Substance Use Disorders

Recent statistics suggest that drug use is a
significant social problem

22 million people in the U.S. have used an
illegal substance within the past month

Almost 24% of all high school seniors have
used an illegal drug within the past month
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Substance Use Disorders

What is a drug?

Any substance other than food that affects our
bodies or minds


Need not be a medicine or illegal
Current language uses the term “substance”
rather than “drug” to overtly include alcohol,
tobacco, and caffeine
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Substance Use Disorders

Substances may cause temporary changes in
behavior, emotion, or thought

May result in substance intoxication (literally,
“poisoning”), a temporary state of poor judgment,
mood changes irritability, slurred speech, and poor
coordination

Some substances such as LSD may produce a
particular form of intoxication, sometimes called
hallucinosis, which consists of perceptual
distortions and hallucinations
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Substance Use Disorders

Substances can also lead to long-term
problems:


Substance use disorder: a pattern of maladaptive
behaviors and reactions brought about by
repeated use of substances
In many cases, people become physically
dependent on the substances, developing a
tolerance for it (needing increasing doses to get an
effect) and experiencing withdrawal reactions
(unpleasant and dangerous symptoms when
substance use is stopped or cut down)
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Substance Use Disorders

About 9% of all teens and adults in the U.S.
display substance use disorders

The highest rate in the U.S. is found among
American Indians (15.5%), while the lowest is
among Asian Americans (3.5%)

White Americans, Hispanic Americans, and
African Americans display rates between 9
and 10%

Only 11% receive treatment from a mental health
professional
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Substance Use Disorders

The substances people misuse fall into
several categories:

Depressants

Stimulants

Hallucinogens

Cannabis
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants

Depressants slow the activity of the central
nervous system (CNS)



Reduce tension and inhibitions
May interfere with judgment, motor activity, and
concentration
Three most widely used depressants:



Alcohol
Sedative-hypnotic drugs
Opioids
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

The World Health Organization estimates
that 2 billion people worldwide consume
alcohol

In the U.S., more than half of all residents
drink alcoholic beverages from time to
time
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

When people consume 5 or more drinks in
a single occasion, it is called a bingedrinking episode


24% of all people in the U.S. over the age of 11,
most of them male, binge-drink each month
Nearly 7% of people over age the age of 11
binge-drink at least 5 times each month

Considered heavy drinkers, males outnumber
females by more than 2:1 (around 8% to 4%)
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

All alcoholic beverages contain ethyl
alcohol

It is absorbed into the blood through the
stomach lining and takes effect in the
bloodstream and CNS

Short-term: alcohol binds to certain neurons

Alcohol helps GABA (an inhibitory messenger)
shut down neurons and relax the drinker
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

The first brain area affected is that which
controls judgment and inhibition

Next affected are additional areas in the
CNS, leaving the drinker even less able to
make sound judgments, speak clearly, and
remember well

Motor difficulties increase as drinking
continues, and reaction times slow
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

The extent of the effect of ethyl alcohol is
determined by its concentration (proportion) in the
blood


A given amount of alcohol has a lesser effect on a large
person than on a small one
Gender also affects blood alcohol concentration


Women have less alcohol dehydrogenase, an enzyme
in the stomach that metabolizes alcohol before it
enters the blood
Women become more intoxicated than men on equal
doses of alcohol
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

Levels of impairment are closely tied to the
concentration of ethyl alcohol in the blood:

BAC = 0.06: Relaxation and comfort

BAC = 0.09: Intoxication

BAC > 0.55: Death

Most people lose consciousness before they can
drink this much
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

The effects of alcohol subside only after
alcohol is metabolized by the liver

The average rate of this metabolism is 25% of
an ounce per hour

You can’t increase the speed of this process!
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Alcohol Use Disorder

Though legal, alcohol is one of the most
dangerous recreational drugs

Its effects can extend across the life span

Alcohol use is a major problem on college
campuses
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Alcohol Use Disorder

Surveys indicate that 7.4% of all adults in
the U.S. display alcohol use disorder over a
one-year period while over 13% display it at
some point in their lives

Men outnumber women 2:1

Many teenagers also experience the disorder
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Alcohol Use Disorder

The prevalence of alcoholism in a given year is
about the same (7% to 9%) for White
Americans, African Americans and Hispanic
Americans


The men in these groups show strikingly different
age patterns
American Indians, particularly men, tend to
display a higher rate of alcohol use disorders
than any of these groups

Overall 15% of them have the disorder
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Alcohol Use Disorder

Generally, Asians have lower rates of
alcohol disorders than do people from
other cultures

As many as one-half of these individuals have a
deficiency of alcohol dehydrogenase; thus, they
have a negative reaction to even modest
alcohol intake
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Alcohol Use Disorder

Clinical Picture

In general, people with alcohol use disorder
drink large amounts regularly and rely on it to
enable them to do things that would otherwise
make them anxious


Eventually the drinking interferes with social
behavior and the ability to think and work
Individual patterns of alcoholism abuse vary
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Alcohol Use Disorder

Tolerance and Withdrawal

For many individuals, alcohol use disorder
includes the symptoms of tolerance and
withdrawal reactions



As their bodies build up a tolerance for alcohol, they
need to drink greater amounts to feel its effects
They may experience withdrawal symptoms, including
nausea and vomiting, when they stop drinking
A small percentage of these people experience a
dramatic and dangerous withdrawal syndrome known as
delirium tremens (“the DTs”)

Alcohol withdrawal can be fatal
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

What is the personal and social impact of
alcoholism?

Alcoholism destroys families, social
relationships, and careers

Losses to society total many billions of dollars
annually

Plays a role in suicides, homicides, assaults, rapes,
and accidents

Has serious effects on the children (some 30
million) of persons with this disorder
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Alcohol

What is the personal and social impact of
alcoholism?

Long-term excessive drinking can seriously
damage physical health


Long-term excessive drinking can cause major
nutritional problems


Especially damaged is the liver (cirrhosis)
Example: Korsakoff’s syndrome
Women who drink alcohol during pregnancy place
their fetuses at risk from fetal alcohol syndrome
(FAS) and increased risk of miscarriage
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants:
Sedative-Hypnotic Drugs


Sedative-hypnotic (anxiolytic) drugs
produce feelings of relaxation and
drowsiness

At low doses, they have a calming or sedative
effect

At high doses, they function as sleep inducers
or hypnotics
Sedative-hypnotic drugs include
barbiturates and benzodiazepines
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Barbiturates

First discovered more than 100 years ago,
barbiturates were widely prescribed in the
first half of the 20th century to fight
anxiety and to help people sleep

Although still prescribed, they have been
largely replaced by benzodiazepines

They can cause many problems, not the least
of which is misuse
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Barbiturates

Barbiturates are usually taken in pill or
capsule form

At low doses, they reduce excitement in a
manner similar to alcohol by attaching to
the GABA receptors and helping GABA
operate

Also similar to alcohol, barbiturates are
metabolized by the liver
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Barbiturates

At too high a level, they can halt breathing,
lower blood pressure, and can lead to coma
and death
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Barbiturates

Repeated use of barbiturates can quickly
result in sedative-hypnotic use disorder

A great danger of barbiturate tolerance is that
the lethal dose of the drug remains the same,
even while the body is building a tolerance for
the sedative effects

Barbiturate withdrawal is particularly
dangerous because it can cause convulsions
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Benzodiazepines

Benzodiazepines are often prescribed to
relieve anxiety

Most popular sedative-hypnotics available

Class includes Xanax, Ativan, and Valium
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Benzodiazepines

Benzodiazepines have a depressant effect
on the CNS by binding to GABA receptors
and increasing GABA activity

Unlike barbiturates and alcohol, however,
benzodiazepines relieve anxiety without
causing drowsiness

They are also less likely to slow breathing and lead
to death by overdose
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Benzodiazepines

Once thought to be a safe alternative to
other sedative-hypnotic drugs,
benzodiazepines can cause intoxication
and lead to an addictive pattern of use

As many as 1% of U.S. adults display a sedativehypnotic use disorder that centers on
benzodiazepines at some point in their lives
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Opioids

This class of drug includes both natural
(opium, heroin, morphine, codeine) and
synthetic (methadone) compounds and is
known collectively as “narcotics”

Each drug has a different strength, speed of
action, and tolerance level
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Opioids

Narcotics are smoked, inhaled, injected by needle
just under the skin (“skin popped”), or injected
directly into the bloodstream (“mainlined”)

Injection seems to be the most common method of
use, although other techniques have been increasing in
recent years

An injection quickly brings on a “rush” – a spasm of
warmth and ecstasy that is sometimes compared with
orgasm

This spasm is followed by several hours of pleasurable
feelings (called a “high” or “nod”)
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Opioids

Opioids create these effects by depressing the
CNS



Opioids bind to the receptors in the brain that
ordinarily receive endorphins (NTs that naturally
help relieve pain and decrease emotional tension)
When these sites receive opioids, they produce
pleasurable and calming feelings, just as
endorphins do
In addition to reducing pain and tension, opioids
can cause nausea, narrowing of the pupils, and
constipation
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Opioids

Heroin use exemplifies the problems posed by
opioids:

After just a few weeks, users may become caught
in a pattern of abuse (and often dependence)

Users quickly build a tolerance for the drug and
experience withdrawal when they stop taking it

Early withdrawal symptoms include anxiety and
restlessness; later symptoms include twitching,
aches, fever, vomiting, diarrhea, and weight loss
from dehydration
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Opioids

Such individuals soon need the drug just to
avoid experiencing withdrawal, and they
must continually increase their doses in
order to achieve even that relief

Many users must turn to criminal activity
to support their “habit” and avoid
withdrawal symptoms
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Opioids

Surveys suggest that close to 1% of adults in
the U.S. display opioid use disorder at some
time in their lives
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Opioids

What are the dangers of opioid use ?

Once again, heroin provides a good example:

The most immediate danger is overdose

The drug closes down the respiratory center in the brain,
paralyzing breathing and causing death


Death is particularly likely during sleep
Ignorance of tolerance is also a problem

People who resume use after having avoided it for some
time often make the fatal mistake of taking the same dose
they had built up to before
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Depressants: Opioids

What are the dangers of opioid use?

Each year approximately 2% of persons
addicted to heroin and other opioids die under
the drug’s influence

In addition, users run the risk of getting
impure drugs


Opioids are often “cut” with noxious chemicals
Dirty needles and other equipment can spread
infection
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Stimulants

Stimulants are substances that increase the activity
of the central nervous system (CNS)



Cause increases in blood pressure, heart rate, and
alertness
Cause rapid behavior and thinking
The four most common stimulants are:




Cocaine
Amphetamines
Caffeine
Nicotine
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Stimulants: Cocaine

Derived from the leaves of the coca plant,
cocaine is the most powerful natural
stimulant known

28 million people in the U.S. have tried cocaine

1.6 million people are currently using it
Comer, Abnormal Psychology, 8e
DSM-5 Update
42
Stimulants: Cocaine

Cocaine produces a euphoric rush of wellbeing

It seems to work by increasing dopamine at
key receptors in the brain and
overstimulating them

Also appears to increase norepinephrine and
serotonin
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Stimulants: Cocaine

High doses of cocaine can produce cocaine
intoxication, whose symptoms include
mania, paranoia, and impaired judgment


Some people also experience hallucinations
and/or delusions, a condition known as
cocaine-induced psychosis
As the stimulant effects of the drug
subside, the user experiences a depressionlike letdown, popularly called “crashing”
Comer, Abnormal Psychology, 8e
DSM-5 Update
44
Stimulants: Cocaine

Cocaine use in the past was limited by the
drug’s high cost

Since 1984, newer, more powerful, and
sometimes cheaper versions of the drug have
become available, including:

A “freebase” form where the drug is heated and
inhaled with a pipe

“Crack,” a powerful form of freebase that has been
boiled down for smoking in a pipe
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Stimulants: Cocaine

What are the dangers of cocaine?

Aside from its behavioral effects, cocaine poses
significant physical danger

The greatest danger of use is the risk of overdose

Excessive doses depress the brain’s respiratory function,
and stop breathing

Cocaine use can also cause heart failure

Pregnant women who use cocaine have an increased
likelihood of miscarriage and of having children with
abnormalities
Comer, Abnormal Psychology, 8e
DSM-5 Update
46
Stimulants: Amphetamines

Amphetamines are stimulant drugs that are
manufactured in the laboratory

Most often taken in pill or capsule form

Some people inject the drugs intravenously or
smoke them for a quicker, more powerful effect
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Stimulants: Amphetamines

Like cocaine, amphetamines:

Increase energy and alertness and reduce
appetite when taken in small doses

Produce a rush, intoxication, and psychosis in
high doses

Cause an emotional letdown as they leave the
body

stimulate the CNS by increasing dopamine,
norepinephrine, and serotonin
Comer, Abnormal Psychology, 8e
DSM-5 Update
48
Stimulants: Amphetamines

One kind of amphetamine,
methamphetamine, has had a major surge in
popularity in recent years



Almost 6% of all persons over the age of 11 in the
US have used this stimulant at least once
Most of the nonmedical meth is made in
“stovetop laboratories”
Meth is about as likely to be used by women
as men and has gained popularity as a “club
drug”
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Stimulant Use Disorder

Regular use of either cocaine or amphetamine
may lead to stimulant use disorder



The stimulant comes to dominate the individual’s
life
Tolerance and withdrawal reactions may also
develop
In a given year, 0.5% of all people over the age
of 11 display stimulant use disorder centered
on cocaine and 0.25 display it centered on
amphetamines
Comer, Abnormal Psychology, 8e
DSM-5 Update
50
Stimulants: Caffeine

Caffeine is the world’s most widely used
stimulant

Around 80% of the world’s population
consumes it daily

Most consumption is in the form of coffee; the rest
is in the form of tea, cola, energy drinks, chocolate,
and over-the-counter medications

Around 99% of ingested caffeine is absorbed by the
body and reaches its peak concentration within an
hour
Comer, Abnormal Psychology, 8e
DSM-5 Update
51
Stimulants: Caffeine

Caffeine acts as a stimulant in the CNS,
producing a release of dopamine,
serotonin, and norepinephrine in the brain

More than 2 to 3 cups of brewed coffee can
lead to caffeine intoxication

Seizures and respiratory failure can occur at
doses greater than 10 grams of caffeine (about
100 cups of coffee)
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Stimulants: Caffeine

Many people who suddenly stop or cut back
their usual intake experience withdrawal
symptoms, including headaches, depression,
anxiety, and fatigue

Studies suggest correlations between high doses of
caffeine and heart rhythm irregularities, high
cholesterol levels, and risk of heart attacks

High doses during pregnancy also increase the risk of
miscarriage
Comer, Abnormal Psychology, 8e
DSM-5 Update
53
Hallucinogens, Cannabis, and
Combinations of Substances

Other kinds of substances may also cause
problems for users and for society

Hallucinogens


Cannabis


Produce delusions, hallucinations, and other sensory
changes
Produces sensory changes, but have both depressant and
stimulant effects
Many individuals take combinations of substances
Comer, Abnormal Psychology, 8e
DSM-5 Update
54
Hallucinogens

Hallucinogens, also known as psychedelic
drugs, cause powerful changes in sensory
perceptions (sometimes called “trips”)


Include natural hallucinogens

Mescaline

Psilocybin
And laboratory-produced hallucinogens

Lysergic acid diethylamide (LSD)

MDMA (Ecstasy)
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Hallucinogens

LSD is one of the most famous and powerful
hallucinogens

Within two hours of being swallowed, it brings on
a state of hallucinogen intoxication (hallucinosis)


Increased and altered sensory perception
Hallucinations may occur




The drug may cause different senses to cross, an effect called
synesthesia
May induce extremely strong emotions
May have some physical effects
Effects wear off in about six hours
Comer, Abnormal Psychology, 8e
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Hallucinogens

LSD produces these symptoms by binding
to serotonin receptors

These neurons help control visual information
and emotions, thereby causing the various
effects of the drug on the user
Comer, Abnormal Psychology, 8e
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Hallucinogens

More than 14% of Americans have used
hallucinogens at some point in their lives

Tolerance and withdrawal are rare

But the drugs do pose dangers


Users may experience a “bad trip” – the experience
of enormous unpleasant perceptual, emotional, and
behavioral reactions
Another danger is the risk of “flashbacks”

Can occur days or months after last drug use
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Cannabis

The drugs produced from varieties of the
hemp plant are, as a group, called cannabis

They include:



Hashish, the solidified resin of the cannabis plant
Marijuana, a mixture of buds, crushed leaves, and
flowering tops
The major active ingredient in cannabis is
tetrahydrocannabinol (THC)

The greater the THC content, the more powerful
the drug
Comer, Abnormal Psychology, 8e
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Cannabis

When smoked, cannabis produces a mixture of
hallucinogenic, depressant, and stimulant effects



At low doses, the user feels joy and relaxation

May become anxious, suspicious, or irritated

This overall “high” is technically called cannabis intoxication
At high doses, cannabis produces odd visual
experiences, changes in body image, and
hallucinations
Most of the effects of cannabis last 2 to 6 hours

Mood changes may continue longer
Comer, Abnormal Psychology, 8e
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Cannabis

Cannabis Use Disorder

In the 1970s, use of marijuana rarely led to
cannabis use disorder

Today many users are developing this disorder

Some users develop tolerance and withdrawal,
experiencing flulike symptoms, restlessness, and
irritability when drug use is stopped

About 1.7% of people in the U.S. displayed marijuana
abuse or dependence in the past year

Between 4 and 5% will fall into these patterns at some point
in their lives
Comer, Abnormal Psychology, 8e
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Cannabis

Cannabis Use Disorder

One theory about the increase in cannabis use
disorder is the change in the drug itself

The marijuana available today is significantly more
potent than the drug used in the early 1970s
Comer, Abnormal Psychology, 8e
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Cannabis

Is marijuana dangerous?

As the strength and use of the drug has
increased, so have the risks of using it

May cause panic reactions similar to those caused
by hallucinogens

Because of its sensorimotor effects, marijuana has
been implicated in accidents

Marijuana use has been linked to poor
concentration and impaired memory
Comer, Abnormal Psychology, 8e
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Cannabis

Is marijuana dangerous?

Long-term use poses additional dangers

May cause respiratory problems and lung cancer

May affect reproduction

In males, it may lower sperm count

In women, abnormal ovulation has been found
Comer, Abnormal Psychology, 8e
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Cannabis

Cannabis and Society: A Rocky Relationship

For centuries, cannabis played a respected role
in medicine, but its use fell out of favor and
was criminalized

In the late 1980s, several interest groups
campaigned for the medical legalization of
marijuana
Comer, Abnormal Psychology, 8e
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Cannabis

Cannabis and Society: A Rocky Relationship

In 2009, the US Attorney General directed
federal prosecutors to not pursue cases against
medical marijuana users complying with state
laws

In 2011 and 2012, several state and city-level
officials petitioned the government to
reclassify marijuana as a drug with acceptable
medical usage
Comer, Abnormal Psychology, 8e
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Cannabis

Cannabis and Society: A Rocky Relationship


In 2012, residents of Colorado and Washington
voted to legalize marijuana for use of any kind,
although such state measures can be blocked
by the federal government
In the meantime, both the Netherlands and
Canada permit its use for medical purposes
Comer, Abnormal Psychology, 8e
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Combinations of Substances

People often take more than one drug at a
time, a pattern called polysubstance use

Researchers have studied the ways in which
drugs interact with one another, focusing on
cross-tolerance and synergistic effects
Comer, Abnormal Psychology, 8e
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Combinations of Substances

Cross-tolerance

Sometimes two or more drugs are so similar in
their actions on the brain and body that as people
build a tolerance for one drug, they are
simultaneously developing a tolerance for the
other (even if they have never taken it)

Users who display this cross-tolerance can reduce
the symptoms of withdrawal from one drug by
taking the other

Example: alcohol and benzodiazepines
Comer, Abnormal Psychology, 8e
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Combinations of Substances

Synergistic effects

When different drugs are in the body at the
same time, they may multiply, or potentiate,
each other’s effects

This combined impact is called a synergistic
effect, and is often greater than the sum of the
effects of each drug taken alone
Comer, Abnormal Psychology, 8e
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Combinations of Substances

Synergistic effects

One kind of synergistic effect occurs when two
or more drugs have similar actions

Example: alcohol, barbiturates, benzodiazepines,
and opioids

All depressants, these drugs may severely depress
the CNS when mixed, leading to death
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Combinations of Substances

Synergistic effects

A different kind of synergistic effect results
when drugs have opposite (antagonistic)
effects

Example: stimulants or cocaine with barbiturates or
alcohol

May build up lethal levels of the drugs because of
metabolic issues (stimulants impede the liver’s processing
of barbiturates and alcohol)
Comer, Abnormal Psychology, 8e
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Combinations of Substances

Each year tens of thousands of people are
admitted to hospitals because of
polysubstance use

May be accidental or intentional

As many as 90% of people who use one illegal drug
are also using another to some extent
Comer, Abnormal Psychology, 8e
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What Causes
Substance Use Disorders?

Clinical theorists have developed
sociocultural, psychological, and biological
explanations for substance abuse and
dependence

No single explanation has gained broad
support

Best explanation: a COMBINATION of factors
Comer, Abnormal Psychology, 8e
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Causes of Substance Use Disorders:
Sociocultural Views

A number of theorists propose that people
are more likely to develop substance use
disorders when living in stressful
socioeconomic conditions

Example: higher levels of unemployment
correlate with higher rates of alcohol use

Example: people of lower SES have higher rates
of substance use in general
Comer, Abnormal Psychology, 8e
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Causes of Substance Use Disorders:
Sociocultural Views

Other theorists propose that substance use
disorders are more likely to appear in
families and social environments where
substance use is valued or accepted

Example: rates of alcohol use vary among
cultures
Comer, Abnormal Psychology, 8e
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Causes of Substance Use Disorders:
Psychodynamic Views

Psychodynamic theorists believe that people with
substance use disorders have powerful dependency
needs that can be traced to their early years

Caused by a lack of parental nurturing


Some people may develop a “substance abuse personality” as a
result
Limited research does link early impulsivity to later
substance use, but the findings are correlational and
researchers cannot presently conclude that any one
personality trait or group of traits stands out in
substance-related disorders
Comer, Abnormal Psychology, 8e
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Causes of Substance Use Disorders:
Cognitive-Behavioral Views

According to behaviorists, operant
conditioning may play a key role in substance
abuse

They argue that the temporary reduction of
tension produced by a drug has a rewarding effect,
thus increasing the likelihood that the user will
seek this reaction again

Similarly, the rewarding effects may also lead users
to try higher doses or more powerful methods of
ingestion
Comer, Abnormal Psychology, 8e
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Causes of Substance Use Disorders:
Cognitive-Behavioral Views

Cognitive theorists further argue that such
rewards eventually produce an expectancy
that substances will be rewarding, and this
expectation is sufficient to motivate
individuals to increase drug use at times of
tension
Comer, Abnormal Psychology, 8e
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Causes of Substance-Related
Disorders: Cognitive-Behavioral Views

In support of these views, studies have
found that many subjects do in fact drink
more alcohol or seek heroin when they feel
tense

In a manner of speaking, this model is
arguing a “self-medication” hypothesis
Comer, Abnormal Psychology, 8e
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Causes of Substance-Related
Disorders: Cognitive-Behavioral Views

If true, one would expect higher rates of
substance use among people with
psychological problems

More than 22% of all adults who suffer from
psychological disorders have displayed
substance use disorders within the past year
Comer, Abnormal Psychology, 8e
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Causes of Substance-Related
Disorders: Cognitive-Behavioral Views

Other behaviorists have proposed that
classical conditioning may play a role in these
disorders

Objects present at the time drugs are taken may
act as classically conditioned stimuli and come to
produce some of the pleasure brought on by the
drugs themselves

Although classical conditioning may be at work, it
has not received widespread research support as
the key factor in such patterns
Comer, Abnormal Psychology, 8e
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Causes of Substance Use
Disorders: Biological Views

In recent years, researchers have come to
suspect that drug misuse may have
biological causes

Studies on genetic predisposition and
specific biochemical processes have
provided some support for this model
Comer, Abnormal Psychology, 8e
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Causes of Substance Use
Disorders: Biological Views

Genetic predisposition

Research with “alcohol-preferring” animals has
demonstrated that their offspring have similar
alcohol preferences

Similarly, research with human twins has
suggested that people may inherit a
predisposition to misuse substances

Concordance rates in identical (MZ) twins: 54%

Concordance rates in fraternal (DZ) twins: 28%
Comer, Abnormal Psychology, 8e
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Causes of Substance Use
Disorders: Biological Views

Genetic predisposition

Clearer support for a genetic model may come
from adoption studies

Studies compared adoptees whose biological
parents abuse alcohol with adoptees whose
biological parents do not

By adulthood, those whose biological parents were
dependent showed higher rates of alcoholism themselves
Comer, Abnormal Psychology, 8e
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Causes of Substance Use
Disorders: Biological Views

Genetic predisposition

Genetic linkage strategies and molecular
biology techniques provide more direct
evidence in support of this hypothesis

An abnormal form of the dopamine-2 (D2) receptor
gene was found in the majority of research
participants with substance use disorders, but in
less than 20% of participants who do not display
such disorders
Comer, Abnormal Psychology, 8e
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Causes of Substance Use
Disorders: Biological Views

Biochemical factors

Over the past few decades, investigators have
pieced together several biological explanations of
drug tolerance and withdrawal

Based on NT functioning in the brain


The specific NTs affected depend on which drug is used
Recent brain imaging studies have suggested that
many (perhaps all) drugs eventually activate a
reward center or “pleasure pathway” in the brain
Comer, Abnormal Psychology, 8e
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Causes of Substance Use
Disorders: Biological Views

Biochemical factors


The reward center apparently extends from the ventral
tegmental area of the brain to the nucleus accumbens and
on to the frontal cortex
The key NT appears to be dopamine


Certain drugs stimulate the reward center directly


When dopamine is activated at this reward center, a person
experiences pleasure
Examples: cocaine, amphetamines, caffeine
Other drugs stimulate the reward center in roundabout
ways

Examples: alcohol, opioids, marijuana
Comer, Abnormal Psychology, 8e
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Causes of Substance Use
Disorders: Biological Views

Biochemical factors

A number of theorists believe that when
substances repeatedly stimulate the reward
center, the center develops a hypersensitivity
to the substances

This theory, called the incentive-sensitization
theory, has received considerable support in animal
studies
Comer, Abnormal Psychology, 8e
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Causes of Substance Use
Disorders: Biological Views

Biochemical factors

Other theorists believe that people who abuse
substances suffer from a reward-deficiency
syndrome

Their reward center is not readily activated by
“normal” life events so they turn to drugs to
stimulate this pleasure pathway, particularly in
times of stress

Defects in D2 receptors have been cited as a possible
cause
Comer, Abnormal Psychology, 8e
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How Are Substance Use
Disorders Treated?

Many approaches have been used to treat
substance use disorders, including psychodynamic,
behavioral, cognitive-behavioral, and biological,
along with sociocultural therapies

Although these treatments sometimes meet with
great success, more often they are only moderately
helpful

Today treatments are typically used in combination
on both an outpatient and inpatient basis
Comer, Abnormal Psychology, 8e
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How Are Substance Use
Disorders Treated?

The value of treatment for substance use
disorders can be difficult to determine




Different substance use disorders pose different
problems
Many people with such disorders drop out of
treatment early
Some people recover without any intervention at
all
Different criteria are used by different clinical
researchers
Comer, Abnormal Psychology, 8e
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Psychodynamic Therapies


Psychodynamic therapists first guide clients to
uncover and work through the underlying
needs and conflicts that they believe led to the
disorder then try to help them change their
styles of living
Research has not found this model to be very
effective

Tends to be of greater help when combined with
other approaches in a multidimensional treatment
program
Comer, Abnormal Psychology, 8e
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Behavioral Therapies

A widely used behavioral treatment is
aversion therapy, an approach based on
classical conditioning principles

Individuals are repeatedly presented with an
unpleasant stimulus at the very moment they
are taking a drug

After repeated pairings, they are expected to
react negatively to the substance itself and to
lose their craving for it
Comer, Abnormal Psychology, 8e
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Behavioral Therapies

Aversion therapy is most commonly applied
to alcoholism

In one version, drinking behavior is paired with
drug-induced nausea and vomiting

Another version of this approach requires people
with alcoholism to imagine extremely upsetting,
repulsive, or frightening scenes while they are
drinking

The pairing is expected to produce negative responses to
liquor itself
Comer, Abnormal Psychology, 8e
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Behavioral Therapies

A behavioral approach that has been
successful in the short-term is contingency
management

This procedure makes incentives contingent on
the submission of drug-free urine specimens
Comer, Abnormal Psychology, 8e
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Behavioral Therapies

Behavioral interventions have usually had
onlhy limited success when used alone

They work best when used in combination
with either biological or cognitive approaches
Comer, Abnormal Psychology, 8e
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Cognitive-Behavioral Therapies

Cognitive-behavioral treatments for
substance use disorders help clients
identify and change the patterns and
cognitions contributing to their patterns of
substance misuse
Comer, Abnormal Psychology, 8e
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Cognitive-Behavioral Therapies

The most prominent of these approaches is
relapse-prevention training

The overall goal is for clients to gain control over
their substance-related behaviors


Clients are taught to identify and plan ahead for highrisk situations and to learn from mistakes and lapses
This approach is used particularly to treat alcohol
use; also used to treat cocaine and marijuana
abuse
Comer, Abnormal Psychology, 8e
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Biological Treatments

Biological approaches may be used to help
people withdraw from substances, abstain
from them, or simply maintain their level
of use without further increases

These approaches have limited long-term
success when used alone, but can be helpful
when combined with other approaches
Comer, Abnormal Psychology, 8e
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Biological Treatments

Detoxification

Systematic and medically supervised
withdrawal from a drug


Can be outpatient or inpatient
Two strategies:

Gradual withdrawal by tapering doses of the
substance

Induce withdrawal but give additional medication
to block symptoms
Comer, Abnormal Psychology, 8e
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Biological Treatments

Detoxification

Detoxification programs seem to help
motivated people withdraw from drugs

For people who fail to receive psychotherapy after
withdrawal, however, relapse rates tend to be high
Comer, Abnormal Psychology, 8e
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Biological Treatments

Antagonist drugs

As an aid to resist falling back into a pattern of
substance abuse or dependence, antagonist
drugs block or change the effects of the
addictive substance

Example: disulfiram (Antabuse) for alcohol

Example: naloxone for opioids, naltrexone for
alcohol
Comer, Abnormal Psychology, 8e
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Biological Treatments

Drug maintenance therapy

A drug-related lifestyle may be a greater problem
than the drug’s direct effects


Example: heroin addiction
Methadone maintenance programs are designed to
provide a safe substitute for heroin


Methadone is a laboratory opioid with a long half-life,
taken orally once a day
Programs were roundly criticized as “substituting
addictions” but are regaining popularity, partly because
of the spread of HIV/AIDS
Comer, Abnormal Psychology, 8e
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Sociocultural Therapies

Three sociocultural approaches have been
applied to substance use disorders:

Self-help programs

Culture- and gender-sensitive programs

Community prevention programs
Comer, Abnormal Psychology, 8e
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Sociocultural Therapies

Self-help and residential treatment
programs

Most common: Alcoholics Anonymous (AA)

Offers peer support along with moral and spiritual
guidelines to help people overcome alcoholism

It is worth noting that the abstinence goal of AA
directly opposes the controlled-drinking goal of
relapse prevention training and several other
interventions for substance misuse – this issue has
been debated for years
Comer, Abnormal Psychology, 8e
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Sociocultural Therapies

Self-help and residential treatment
programs

Many self-help programs have expanded into
residential treatment centers or therapeutic
communities

People formerly addicted to drugs live, work, and
socialize in a drug-free environment while
undergoing individual, group, and family therapies
Comer, Abnormal Psychology, 8e
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Sociocultural Therapies

Culture- and gender-sensitive programs

A growing number of treatment programs try
to be sensitive to the special sociocultural
pressures and problems faced by drug abusers
who are poor, homeless, or members of ethnic
minority groups

Similarly, therapists have become more aware
that women often require treatment methods
different from those designed for men
Comer, Abnormal Psychology, 8e
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Sociocultural Therapies

Community prevention programs

Perhaps the most effective approach to substance use
disorders is to prevent them

Some prevention programs argue for total abstinence
from drugs, while others teach responsible use

Prevention programs may focus on the individual, the
family, the peer group, the school, or the community
at large

The most effective of these prevention efforts focuses on
multiple areas to provide a consistent message about drug use
in all areas of life
Comer, Abnormal Psychology, 8e
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Gambling Disorder

It is estimated that as many as 2.3% of all
adults and 3-8% of teens and college students
suffer from gambling disorder


Clinicians are careful to distinguish between this
disorder and social gambling
Gambling disorder is defined less by the
amount of time or money spent than by the
addictive nature of the disorder

People with the disorder are preoccupied with and
cannot walk away from a bet
Comer, Abnormal Psychology, 8e
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Gambling Disorder

The explanations posed for gambling
disorder often parallel those offered for
substance use disorders

These include possible genetic predisposition,
heightened dopamine activity, impulsive
personality styles, and cognitive errors

Research, however, has been limited thus far
Comer, Abnormal Psychology, 8e
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Gambling Disorder

Similarly, the leading treatments for
substance use disorder have been adapted
for use with gambling disorder

These include cognitive-behavioral approaches
and biological approaches

In addition, the self-help group program
Gamblers Anonymous is available
Comer, Abnormal Psychology, 8e
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Internet Use Disorder

As people increasingly turn to the Internet
for activities that used to take place in the
“real world”, a new psychological problem
has emerged: an uncontrollable need to be
online

This pattern has been called Internet use
disorder, Internet addiction, and problematic
Internet use
Comer, Abnormal Psychology, 8e
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Internet Use Disorder

For people who display this pattern, the
Internet has become a black hole

Sufferers – at least 1% of all people – spend all or
most of their waking hours texting, tweeting,
networking, gaming, Internet browsing, emailing,
blogging, visiting virtual worlds, shopping online,
or viewing online pornography

Specific symptoms of this pattern parallel those
found in substance use disorders and gambling
disorder
Comer, Abnormal Psychology, 8e
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Internet Use Disorder

Although clinicians, the media, and the
public have shown enormous interest in
this problem, DSM-5 has not listed it as a
disorder

Instead, it has recommended that the pattern
receive further study for possible inclusion in
future editions
Comer, Abnormal Psychology, 8e
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