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Abnormal Psychology, Eleventh Editionby Ann M. Kring, Gerald C. Davison, John M. Neale, & Sheri L. Johnson

Chapter 10 Substance Related Disorders

+ Percentage of Indonesian Population Reporting Drug Use in 2003-2006 (Based on BNN survey)

Jakarta : 23%

Medan : 15%

Bandung : 14%

Surabaya : 6.3 %

Maluku utara : 4.3 %

Padang : 5.5 %

Kendari : 5%

Marijuana : 74.9 %

Anti-Depressant : 32.5 %

Ecstasy : 25.7 %

Amphetamine : 21.5 %

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Based on areas Based on substance

+Substance Dependence and Abuse

Occupational or social problems, much time trying to obtain substance, continued use despite problems, etc.

Involves either tolerance or withdrawal Tolerance

Greater amounts required to produce desired effect

Withdrawal Physiological and psychological

consequences when individual discontinues or reduces substance use Restlessness, anxiety,

cramps, death

Maladaptive use of substance No physiological dependence

In 2006, 22 million met criteria for dependence or abuse. Of those 15 million involved

alcohol.

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Dependence ( Adiction) Abuse

+Alcohol Dependence and Abuse

Alcohol abuse Negative social and occupational effects No tolerance, withdrawal, or compulsive usage

Alcohol Dependence More severe symptoms such as tolerance and withdrawal Withdrawal results in:

Anxiety Depression Weakness Restlessness Insomnia Muscle tremors

Face, fingers, eyelids, other small musculature Elevated BP, pulse, temperature

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+Alcohol Abuse and Dependence

Delirium tremens (DTs)Can occur when blood alcohol levels drop

suddenlyResults in:

Deliriousness Tremulousness Hallucinations

Primarily visual; may be tactile

2.5% of alcohol abusers develop dependence

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+Alcohol Abuse and Dependence

Polydrug abuse Many users abuse multiple substances

e.g., cigarettes, cocaine, marijuana 85% of alcohol are smokers

Synergistic Some combinations of drugs produce stronger

reaction Alcohol and barbiturates

May cause death Alcohol and heroin

Alcohol reduces amount of heroin needed to produce lethal dose

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+Prevalence of Alcohol Abuse

Lifetime prevalence (Kessler et al., 1994) 20% for men 8% for women

Lifetime prevalence: Abuse - 17% Dependence – 12%

Binge drinking 5 drinks in short period 43.5% prevalence among college students

Heavy use drinking 5 drinks, 5 or more times in a 30 day period

17.6% prevalence among college students

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+Short-term Effects of Alcohol

Enters the bloodstream through small intestine metabolized by the liver

Effects vary by concentration Concentration varies by gender, height,

weight, liver efficiencyAffects brain areas associated with error monitoring and

decision making.

Biphasic effect Initially stimulates Later depresses

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+Short-term Effects of Alcohol

Effect of ingesting large amounts Impaired speech and vision Interference in complex thought processes Poor coordination Loss of balance Depression and withdrawal

Interacts with several neural systems Stimulates GABA receptors Increases dopamine and serotonin Inhibits glutamate receptors

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+Long-term Effects of Alcohol

Malnutrition Alcohol interferes with digestion

and absorption of vitamins from food

Deficiency of B-complex vitamins Amnestic syndrome

Severe loss of memory for both long and 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

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 Fetal growth slowed

Cranial, facial and limb anomalies occur

Moderate alcohol intake 1 drink per day Learning and memory impairments Growth deficits

Total abstinence recommended by NIAAA

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+Nicotine and Cigarette Smoking

Nicotine Addicting agent of tobacco Principal alkaloid

Active chemicals that give drugs their physiological and psychological altering properties

Stimulates dopamine neurons in mesolimbic area Involved in reinforcing effect

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+Prevalence and Health Consequences Prevalence decreased since mid 1960s although use

increased through the 1990s, among white adolescents

More prevalent among white & Hispanic youth than African Americans African Americans less likely to quit and more likely to get

lung cancer Metabolize nicotine more slowly

Chinese Americans have lower lung cancer rates Metabolize less nicotine

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 US

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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

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+Prevalence

Most frequently used illicit drug in US 15,000,000 reported using it in 2006

Peaked in 1979 then began to decline Rose again in 90s

Greater use by men than women although rates among women increased faster in 1990s

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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

Impairment of skills needed for driving Impairment present for

several hours after ‘high’ has worn off

Physiological Bloodshot & itchy eyes Dry mouth and throat Increased appetite Reduced pressure within the

eye Increased BP Abnormal heart rate

May exacerbate preexisting cardiovascular problems

Damage to lung structure and function in long term users

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+Therapeutic Effects of Marijuana

Reduces nausea and loss of appetite caused by chemotherapy (Salan et al., 1975)

Relieves discomfort of AIDS (Sussman et al., 1996)

Analgesic effects due to ability of THC to block pain signals from reaching the brain.

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 Seconal and valium

Opiates legally prescribed as pain medications include: Hydrocodone combined with other substances yields

Vicodin, Zydone, and Lortab Oxycodone the basis for OxyContin, Percodan, & Tylox.

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+Prevalence of Opiate Use

Heroin Estimated1,000,000 individuals addicted to heroin in US

300,000 in 2006 alone From 1995 to 2002, rates of use among adults 18 to 25

increased from 0.8% to 1.6% Accounted for 62 to 82% of drug-related hospital

admissions in Baltimore, Boston, & Newark.

Heroin is more pure (25 to 50%) than in the past Increases likelihood of overdose

OxyContin prescriptions jumped 1800% between 1996 and 2000 (DEA, 2001) 2.8 million users (SAMSHA, 2004)

Can be dissolved for injection or snorting Street price from $25 to $40 per pill

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+Psychological and Physical Effects of Opiates Euphoria, drowsiness, reverie, 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 Endorphins and enkephalins

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, & vomiting Withdrawal lasts about 72 hours

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+Psychological and Physical Effects of Opiates29 year follow up of 500 heroin addicts

(Hser, et al., 1993) 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 reduces

infectious diseases associated with IV drug use

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+Synthetic Sedatives

Barbituates Induce muscle relaxation,

reduce anxiety, produce mild euphoria

In 1940s prescribed to aid sleep

Usage declined from 1975 thru 1990s but increased recently

Other synthetic sedatives Benzodiazepines

e.g., Valium, Ketamine

Stimulate GABA system

Heavy dosages Slurred speech Unsteady gait Impaired judgment &

concentration Irritability & combativeness Accidental suffocation due to

excessive relaxation of diaphragm muscles

Alcohol magnifies depressant effects

Tolerance & withdrawal Delirium, convulsions & other

symptoms

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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 (Comer et al.,

2001)

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+Stimulants: Methamphetamine

Amphetamine derivative (aka crystal meth) Can be taken orally, intravenously, or intranasally

(snorting) In 2006, over 700,000 people used

methamphetamine (SAMHSA, 2007).

Chronic use damages brain Reduction in hippocampus volume (see figure 10.4;

abusers represented by yellow bars)

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+Stimulants: 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 &

death

Not all users develop tolerance Some become more sensitive

May increase risk of OD

In 2006, 2.4 million people over the age of 12 reported using cocaine, and 700,000 reported using crack (SAMHSA, 2007).

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+Stimulants: Cocaine

Crack Form of cocaine that quickly become popular in the 80s Rock crystal that is heated, melted, & smoked Cheaper than cocaine

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+Hallucinogens, Ecstasy, and PCP

Hallucinogen effects include: Colorful visual

hallucinations Synestesias

Overflow from one sensory modality to another

Alterations in time perception

Lability of mood Anxiety & paranoia

LSD d-lysergic acid

diethylamide

Psilocybin Extracted from mushroom

psylocube mexicana

Mescaline Active ingredient of peyote

Ecstasy Increase feelings of intimacy

and enhances mood Chemically similar to

mescaline and amphetamines

PCP (phencyclidine) Angel dust Animal tranquilizer Causes severe paranoia and

violence

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+Figure 10.5 Process of Becoming a Drug Abuser

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+Etiology of Substance-Related Disorders: Developmental approach

Li et al. (2001) Two paths to alcohol abuse 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.

Boys more likely to be in the first group, girls in the second group

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 In men

Alcohol, caffeine, smoking, marijuana, & drug abuse in general In women

Role of genetics less clear Fewer available studies Findings are mixed

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

CYP2A6 Gene associated with metabolism of nicotine Smokers with defect in this gene less likely to become dependent (Rao et al.,

2000)

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+Etiology of Substance-Related Disorders: Neurobiological Factors

Nearly all drugs, including alcohol, stimulate the dopamine system in the brain

Some evidence that people dependent on drugs or alcohol have a deficiency in the dopamine receptor DRD2

People take drugs to avoid the bad feelings associated with withdrawal Explains frequency of relapse

Incentive-sensitization theory (Robinson & Berridge, 19983, 2003) Distinguish

Wanting (craving for drug) 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 & 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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+Etiology of Substance-Related Disorders: Psychological factorsMood alteration

Tension reduction may be due to “alcohol myopia” (Steele & Joseph, 1990) User focuses reduced cognitive capacity on immediate

distractions Less attention focused on tension-producing thoughts

Effect similar for smoking Cognitive distraction also reduces aggressive behavior

in intoxicated individuals However, alcohol and nicotine may increase tension

when no distractions are present.Expectancies about drugs effects influence

behavior People who expect alcohol to reduce stress & anxiety are most

likely to drink The greater perceived risk, the less likely it is to be used

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+ Etiology of Substance-Related Disorders: Psychopathology and Personality

Personality factors that predict onset of substance related disorders: Negative emotionality Desire for increased arousal and positive affect Constraint

Harm avoidance, conservative moral values, & 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-Related Disorders: Sociocultural factors

Alcohol is the most common abused substance worldwide (Smart & Ogborne, 2000)

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

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+Etiology of Substance-Related Disorders: Sociocultural factors

Family factors Parental alcohol use (Hawkins et al., 1997) Psychiatric, marital, or legal problems in the family

linked to drug abuse Lack of emotional support from parents increases

use of cigarettes, marijuana, and alcohol (Cadoret et la., 1995a)

Lack of parental monitoring linked to higher drug usage (Chassin et al., 1996; Thomas et al., 2000)

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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 (Saffer, 1991)

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+ Treatment of Substance Related Disorders: Alcohol Abuse and Dependence

Inpatient hospital treatment Detoxification

Withdrawal from alcohol under medical supervision The therapeutic results of hospital treatment are not superior to those of

outpatient treatment

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 of therapy.

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+ Treatment of Substance Related Disorders: Alcohol Abuse and Dependence

Couples and Family Therapy Emphasizes support from problem drinker’s partner Reduced problem drinking maintained1 year after therapy ended Also reduced couples’ overall level of distress

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+ Treatment of Substance Related Disorders: Alcohol Abuse and Dependence

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

AKA Community-reinforcement approachRelapse Prevention

Strategies to prevent relapse Brief motivational interventions

Designed to curb heavy drinking in college

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+ Treatment of Substance Related Disorders: Alcohol Abuse and Dependence

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, &

acamprosate Most effective when combined with CBT

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+ Treatment of Substance Related Disorders: Nicotine Dependence

Peer behavior important If others in social network stop smoking, increases likelihood that individual

will also stop

Rapid smoking treatment Rapid puffing, focused smoking, & smoke holding

Scheduled smoking Reduce nicotine intake gradually over a few weeks

Physician’s advice By age 65, most smokers have quit (USDHHS, 1998b)

Nicotine replacement treatments Gum, patches, or inhalers Reduce craving for nicotine Combining patch with antidepressants improved success rate

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+ Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence

Detoxification central to treatment Psychological treatments

Desipramine and CBT showed effectiveness for cocaine use CBT especially helpful for users with high dependence levels

(Carroll et al., 1994, 1995) Operant conditioning

Tokens that can be traded for desirable goods are given to users who abstain (Dallery et al., 2001)

Motivational interviewing or enhancement thereapy CBT plus Rogerian therapy effective for alcohol and drug use

(Burke et al., 2003) Self-help residential homes for heroin users

Non-drug environment Group therapy Guidance and support from former users

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+ Treatment of Substance Related Disorders: Illegal Drug Abuse and Dependence

Drug replacement treatments and medicationsA meta-analysis of stimulant medication as a

treatment for cocaine abuse revealed little evidence that this type of medication is effective

Heroin replacements Synthetic narcotics

Methadone, levomethadyl acetate, bupreophine Used to wean heroin users from dependence

More effective if combined with psychological support & treatment (Lilley et al., 2000)

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+Prevention of Substance-Related 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

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